HX641 69340 
RG524  J39  A  manual  oimidwito 


RECAP 


mWM 


m 


HHH9 


Columbia  WLnibtxsity 
mtfceCttpofJIetogork 

College  of  ^fjpstcian*  anb  burgeons; 


1859-1918 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/manualofmidwiferOOjell 


A MANUAL 


MIDWIFERY 

FOR 

STUDENTS  AND  PRACTITIONERS 


BY 

HENRY  JELLETT 

B.A.,  M.D.  (DUB.  UNIV.),  F.R.C.P.I.,  L.M. 

Gynaecologist  and  Obstetric  Physician  to  Dr.  Steevens'  Hospital,  Dublin  ;  Extern  Examiner 

in  Midwifery,  Royal  University  of  Ireland ;  Examiner  in  Midwifery,  Royal 

College  of  Physicians,  Ireland ;  Ex-Assistant  Master,  Rotunda 

Hospital;  Ex-University  Examiner  in  Midwifery 

and  Gynecology,  Dublin  University 

WITH  THE  ASSISTANCE  IN  SPECIAL   SUBJECTS   OF 

W.   R.   DAWSON,  M.I).,  F.R. C.P.I. ,  Medical  Superintendent,  Farnham  House,  Dub- 
lin ;  Examiner  in  Forensic  Medicine,  Royal  College  of  Physicians,  Ireland 

H.  C.  DRTJRY,  M.D.,  F.R.C.P.I.,  Physician  to  Sir  Patrick  Dun's  Hospital,  aud  to 
Cork  Street  Fever  Hospital,  Dublin 

T.  (i.  MOORHEA.D,  M.D.,  Physician  to  the  Royal  City  of  Dublin  Hospital,  Demon- 
strator in  Anatomy,  School  of  Physic,  Trinity  College,  Dublin 

R.  J.  ROWLETTE,  M.D.,  Pathologist  to  the  Rotunda  Hospital,  and  to  Dr.  Steevens' 
Hospital,  Dublin ;  Lecturer  on  Pathology,  Queen's  College,  Galway 


WI1 IT  NINE  PL  A  TES  AND  FOUR  HUNDRED  AND  SIXTY-SEVEN 
ILLUSTRATIONS  IN  THE  TEXT 


NEW  YORK 
WILLIAM   WOOD  &   COMPANY 

aidccccy 


PREFACE 

In  the  following  work,  I  have  endeavoured  to  place  before  my 
readers,  in  a  single  volume,  a  comprehensive  account  of  the  theory 
and  practice  of  modern  obstetrics.  In  doing  so,  I  have  been 
greatly  assisted  by  the  following  gentlemen,  who  have  kindly 
undertaken  to  deal  with  those  subjects  which  require  a  special 
knowledge  of  Anatomy,  General  Medicine,  Pathology,  or  Mental 
Disease.  Dr.  T.  G.  Moorhead  has  contributed  the  chapters  on 
Embryology  and  Anatomy,  and  the  sections  on  the  Phenomena  of 
Pregnancy  and  on  the  Anatomy  of  Contracted  Pelvis ;  Dr.  H.  C. 
Drury  the  chapters  on  Infectious  Diseases  and  on  Organic  and 
Functional  Diseases  in  Pregnancy;  Dr.  R.  J.  Rowlette  the 
sections  on  the  ./Etiology  and  Pathology  of  the  Surgical  Fevers 
of  the  Puerperium  ;  and  Dr.  W.  R.  Dawson  the  sections  on  the 
Insanities  of  Reproduction.  I  think  that  the  special  knowledge 
which  has  been  thus  brought  to  bear  on  these  subjects  will  add 
very  largely  to  the  value  of  the  book. 

Dr.  William  Neville  had  undertaken  the  task  of  writing  the 
chapter  on  the  Surgical  Fevers  of  the  Puerperium — a  task  for 
the  discharge  of  which  his  wide  knowledge,  both  of  practical 
obstetrics  and  of  pathology  and  bacteriology,  rendered  him  par- 
ticularly suitable.  His  sudden  and  premature  death  has  deprived 
me  of  the  assistance  he  had  promised,  and  has  lost  to  the  Irish 
School  of  Midwifery  one  of  its  most  brilliant  workers  and  original 
thinkers. 

The  illustrations  throughout  the  book  have  been  the  subject  of 
great  care.  Most  of  them  are  original,  and  for  these  I  am 
indebted  to  Mr.  J.  T.  Murray,  Mr.  S.  Sewell,  and  Dr.  R.  H. 
Kennan.  The  drawings  of  the  mechanism  of  labour,  and  of 
the  obstetrical  operations,  were  made  from  photographs  taken 
for  me  by  Dr.  Arthur  Ball,  for  whose  assistance  I  am  very 
grateful.     I  am  specially  indebted  to  the  late  Dr.  Milne  Murray, 


viii  PREFACE 

whose  premature  death  was  a  grievous  loss,  not  alone  to  his  own 
Edinburgh  School,  but  to  the  whole  obstetrical  world,  for  permis- 
sion to  make,  from  his  well-known  collection,  the  drawings 
and  diagrams  which  appear  in  the  chapters  upon  contracted 
pelvis.  I  am  also  indebted  to  Professors  Bumm  of  Halle, 
Whitridge  Williams  of  Baltimore,  and  Webster  of  Chicago,  for 
permission  to  reproduce  several  valuable  original  drawings,  and 
to  several  other  authors  for  a  similar  privilege. 

Professor  E.  H.  Bennett  and  Professor  White  have  most  kindly 
afforded  me  every  facility  for  making  use  of  the  valuable  material 
collected  in  the  Museums  of  Trinity  College,  Dublin,  and  of  the 
Royal  College  of  Surgeons  in  Ireland,  and  thus  I  have  been  able 
to  include  illustrations  of  several  valuable  specimens  that  are 
contained  in  these  collections. 

The  chapters  on  Ante  -  partum  Haemorrhage,  Post  -  partum 
Haemorrhage,  and  Eclampsia  have  already  appeared  in  a  slightly 
different  form  in  the  '  Encyclopaedia  Medica,'  published  by 
Messrs.  Green  and  Sons,  of  Edinburgh,  to  whom  I  am  indebted 
for  permission  to  reproduce  them. 

My  colleague,  Dr.  T.  P.  C.  Kirkpatrick,  has  most  kindly 
assisted  me  in  reading  the  proof-sheets,  and  in  many  other  ways. 


HENRY  JELLETT. 


61,  Lower  Mount  Street, 
Merrion  Square,  Dublin. 

April,  1905. 


CONTENTS 

PART    I 

OBSTETRICAL   ANATOMY— MATERNAL   AND 
OVULAR 

CHAPTER  PAGE 

I.  THE    ANATOMY    OF    THE    BONY    PELVIS  -  -  -  -  -  3 

II.  ANATOMY      OF      GENITAL      ORGANS,     PELVIC      FLOOR,     AND      MAMMARY 

GLANDS  -  -  -  -  -  -  30 

III.  THE    OVUM  -  -  -  -  -  69 

IV.  THE    FCETDS  -  -  -----  gg 

PART    II 

OBSTETRICAL   ASEPSIS   AND   ANTISEPSIS 

THE  OBSTETRICAL  ARMAMENTARIUM 

OBSTETRICAL   DIAGNOSIS 

I.    OBSTETRICAL    ASEPSIS    AND    ANTISEPSIS  ...  -       139 

II.    THE    OBSTETRICAL    ARMAMENTARIUM     -----       155 
III.    OBSTETRICAL    DIAGNOSIS  ------       162 

PART    III 
THE   PHYSIOLOGY   OF    PREGNANCY 

I.  THE    MATERNAL    PHENOMENA    OF    PREGNANCY  -  -       205 

II.  THE    DIAGNOSIS    OF    PREGNANCY  ...  .       224 
III.    THE    HYGIENE    OF    PREGNANCY                     -----       245  • 

PART   IV 
THE   PHYSIOLOGY   OF   LABOUR 

I.    THE    CAUSATION    AND    PHENOMENA    OF    LABOUR  -  -       253 

II.  THE    STAGES    AND    PROGNOSIS    OF    LABOUR  -  -  -  .       285 

III.  CEPHALIC    PRESENTATIONS  ------       300 

ix 


x  CONTENTS 

CHAPTER  PAGE 

IV.  THE    MANAGEMENT    OF    NORMAL    LABOUR  -  -  -       332 
V.    CEPHALIC     PRESENTATIONS     {continued) — FACE     PRESENTATION,     BROW      ' 

PRESENTATION,    FONTANELLE    PRESENTATIONS  -  -  -       361 

VI.    PELVIC    PRESENTATION  -  -  -  -  -  -       399 

VII.    TRANSVERSE    AND    OBLIQUE    LIES  -  -  -  -       424 

PART    V 
THE    PHYSIOLOGY   OF   THE    PUERPERIUM 

I.     THE    PHENOMENA    OF    THE    PUERPERIUM  -  -  -       44I 

II.    THE    MANAGEMENT    OF    THE    PUERPERIUM  ...  -       456 

PART   VI 
THE    PATHOLOGY   OF    PREGNANCY 

I.    THE    DISORDERS    OF    PREGNANCY  -----       469 

II.    DISEASES    OF    THE    DECIDU/E    AND    OVUM  -  -       480 

III.  PATHOLOGICAL     CONDITIONS     OF      THE     UTERUS,      THE     VAGINA,     AND 

ADNEXA  --------  529 

IV.  SPECIFIC    INFECTIOUS    DISEASES    IN    PREGNANCY  -  -  554 

V.  ORGANIC    AND    FUNCTIONAL    DISEASES    IN    PREGNANCY                   -                  -  576 
VI.    THE    INTRA-UTERINE    DEATH    OF    THE    FCETUS  -                  -                                     -  614 

VII.     ABORTION MISCARRIAGE PREMATURE     LABOUR — DELAYED     LABOUR       62  I 

VIII.    EXTRA-UTERINE    PREGNANCY       ------       637 

IX.  ANTE-PARTUM    HEMORRHAGES  -  673 

PART    VII 
THE   PATHOLOGY   OF    LABOUR 

I.  ANOMALIES  OF  THE  EXPELLING  FORCES      ...        -  709 

II.  CONTRACTED  PELVIS   -------  720 

III.  THE  COMMON  FORMS  OF  CONTRACTED  PELVIS        -       -   ,    -  739 

IV.  THE  RARE  FORMS  OF  CONTRACTED  PELVIS   -       -        -        -  760 

V.  ANOMALIES  OF  THE  GENITAL  ORGANS        -  791 
VI.  MULTIPLE  PREGNANCY        ......  808 

VII.  COMPOUND   PRESENTATIONS  —  PRESENTATION   AND   PROLAPSE   OF 

THE  CORD    ---.--.-  825 

VIII.     ANOMALIES    OF    FQ3TAL    DEVELOPMENT  -  -  -  84O 

IX.    POST-PARTUM    HEMORRHAGE       -  -  859 

X.  GENITAL    TRAUMATA        -------  877 

PART  VIII 
THE    PATHOLOGY   OF   THE    PUERPERIUM 

1.    THE    SURGICAL    FEVERS    OF    CHILDBED  -  9OI 

II.    DISEASES    ASSOCIATED    WITH    THE    PUERPERIUM  -  -  -       938 


CONTENTS 


PART    IX 
OBSTETRICAL   OPERATIONS 

CHAPTER  IACK 

I.     VARIOUS    OBSTETRICAL    OPERATIONS       -                                                         -                   -  955 

11.    THE    APPLICATION    OF    THE    FORCEPS      -                   -                                                         -  982 

III.  VERSION,   AND    EXTRACTION    IN    PELVIC    PRESENTATION                 -                   -  IOO5 

IV.  CONSERVATIVE    AND    RADICAL    CESAREAN    SECTION — SYMPHYSIOTOMY  IO36 
V.    CRANIOTOMY    AND    EMBRYOTOMY                 .....  1060 


PART  X 
THE    INFANT 

I.  THE  PHYSIOLOGY  AND  CARE  OF  THE  INFANT — INFANT  FEEDING    -  I079 

II.  THE  PATHOLOGY  OF  THE  INFANT    -  ...  1097 


12         OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 

coccyx.  The  transverse  diameter,  on  the  contrary,  becomes  pro- 
gressively smaller  from  above  downwards,  and  thus  gives  to  the 
whole  pelvis  a  slightly  funnel-shaped  appearance.  The  only  really 
important  oblique  measurement  is  that  of  the  brim,  as  elsewhere 
one  of  its  boundaries  is  formed  by  soft  parts,  which  render  it 
capable  of  great  expansion  under  pressure.  The  changes  in  rela- 
tive length  of  the  conjugate  and  transverse  diameters  in  passing 
through  the  pelvic  cylinder  are  probably  of  prime  importance  in 
determining  the  course  which  the  head  of  the  child  takes.  At  the 
inlet  least  resistance  is  experienced  in  the  transverse  or  oblique 
diameter,  and  consequently  the  head  of  the  child  enters  in  this 
direction.      As   it   passes    downwards,    however,    the   transverse 


Fig.  6. — Front  View  of  Pelvis. 
CC,  Iliac  crests  ;  SS',  anterior  superior  iliac  spines ;  TT',  great  trochanters. 


resistance  increases,  while  the  antero-posterior  diminishes,  not 
only  on  account  of  the  greater  length  of  the  conjugate  diameter, 
but  also  owing  to  the  relative  shallowness  of  the  anterior  boundary 
of  this  diameter,  and  hence  the  head  of  the  child  turns  round  and 
passes  along  the  direction  of  least  resistance. 

The  preceding  pelvic  measurements  must  be  regarded  as  being 
merely  the  average  of  a  large  number  of  cases,  since,  as  has  been 
already  stated,  they  are  subject  to  great  individual  differences, 
which  depend  partly,  at  any  rate,  on  the  general  size  and  develop- 
ment of  the  body  as  a  whole.  There  are,  moreover,  marked  racial 
differences,  and  it  has  been  shown  that  there  is  a  coincidence 


THE  PELVIC  AXIS  13 

between  the  prevailing  form  of  the  foetal  skull  and  the  shape  of 
the  pelvis.  In  the  lower  races,  the  ratio  between  the  length  of  the 
conjugate  and  transverse  diameters  of  the  brim  may  vary  widely 
from  that  given  above,  and  the  conjugate  diameter  may  equal, 
or  even  exceed,  the  transverse. 

External  Measurements  of  the  Pelvis. — In  addition  to  the  internal 
diameters  of  the  true  pelvis,  there  are  certain  external  measure- 
ments of  both  the  true  and  the  false  pelvis  which  are  of  consider- 
able importance,  inasmuch  as  they  can  at  all  times  be  readily 
determined  during  life,  and  thus  supply  an  easy  mode  of  diagnos- 
ing the  more  pronounced  forms  of  pelvic  deformity.  The  more 
important  are  as  follows  : — 

(1)  The  inter-spinous  distance — i.e.,  the  distance  between  the  two 
anterior  superior  iliac  spines.  This  measures,  as  a  rule,  about 
10I  inches  (26*5  centimetres),  and  is  always  in  normal  pelves  less 
than  the  distance  between  the  iliac  crests. 

(2)  The  inter-cristal  distance — i.e.,  the  distance  between  the 
widest  parts  of  the  iliac  crests.  This  measures  from  n  to 
11^  inches  (28  to  29  centimetres). 

(3)  The  external  conjugate  diameter,  measured  from  the  spinous 
process  of  the  last  lumbar  vertebra  to  the  upper  margin  of  the 
symphysis  pubis,  averages  8  inches  (20  centimetres). 

(4)  The  inter-trochanteric  distance,  taken  between  the  summits 
of  the  great  trochanters,  measures  12-J-  inches  (31  centimetres). 

(5)  The  distance  between  the  posterior  superior  iliac  spines  is 
about  3^  inches  (9  centimetres). 

Axis  of  the  Pelvis. — There  is  considerable  difficulty  in  defining 
the  exact  axis  of  the  pelvis,  since  the  pelvic  cavity,  though 
approaching  to  the  form  of  a  curved  cylinder,  is  very  irregular ; 
and  it  may  at  once  be  stated  that  the  mode  of  determining  the 
axis  which  is  given  below  is  not  altogether  accurate.  It,  how- 
ever, defines  with  considerable  precision  the  path  along  which 
the  head  of  the  child  moves  during  parturition. 

The  axis  of  any  given  plane  of  the  pelvis  is  a  line  drawn  per- 
pendicularly to  it  at  its  central  point,  and,  equidistant  from  every 
part  of  its  circumference,  assuming  the  plane  to  be  the  section  of 
a  sphere.  Since  it  is  impossible  to  determine  the  exact  centre  of 
any  plane,  however,  it  becomes  necessary  to  adopt  as  a  working 
centre  the  point  of  bisection  of  some  given  line  lying  in  the  plane. 
At  the  brim,  the  middle  of  the  conjugata  vera  is  selected.  A 
line  drawn  at  right  angles  to  it  represents  the  axis  of  the  brim, 
and  would,  if  produced,  cut  the  abdominal  wall  at  the  level  of  the 
umbilicus  above,  and  below  would  strike  the  inferior  extremity 
of  the  coccyx.  Now,  the  symphysis  pubis  may  be  regarded  as 
being  parallel  to  the  upper  two  sacral  vertebrae,  and  is  nearly  of 
the  same  vertical  depth  ;  and  therefore  the  part  of  the  pelvic 
cavity  which  is  enclosed  between  the  plane  of  the  brim  and  a 
plane  extending  between  the  lower  margin  of  the  symphysis  and 
the  junction  of  the   second   and  third  sacral  vertebrae  may  be 


xiv  LIST  OF  ILLUSTRATIONS 

KIG.  1JAGE 

26.  View  of  the  Posterior  Surface  of  the  Uterus,  Fallopian  Tubes,  Ovaries, 

and  Broad  Ligaments.     (Dickinson)            -             -             -             -  40 

27.  Vertical  Section  of  Uterus  (Diagrammatic).     (Ramsbottom)    -            -  41 

28.  Diagram  to  show  Divisions  of  Cervix.     (Schroeder)     -             -             -  41 

29.  Section  of  the  Mucous  Membrane  of  the  Body  of  the  Uterus  at  the  Com- 

mencement of  Pregnancy,  showing  the  Uterine  Glands  (Galabin)  46 

30.  Blood-supply  of  Uterus,  Ovary,  and  Fallopian  Tubes  (Anterior  View) 

(Kelly)            .-..-...  46 

31.  Diagram  of  Blood-supply  of  Uterus  and  Annexa.     (Williams)               -  47 

32.  Lymphatics  of  the  Pelvic  Organs.     (Kelly)        -             -             -             -  48 

33.  Nerves  of  the  Uterus     (Bumm)   -             -             -             -             -             -  49 

34.  Section  through  Isthmus  of  Fallopian  Tube.     (Macalister)      -             -  50 

35.  Transverse  Section  of  Ampulla  of  Fallopian  Tube,  showing  the  Com- 

plicated Arrangement  of  the  Longitudinal  Plications  which  are 

here  cut  across.     (Ahlfeld)  -             -             -             -             -             -  51 

36.  Diagram  of  Uterus  and  Appendages.     (Quain)  -            -            -            -  52 

37.  Vertical  Section  through  the  Broad  Ligament.     (Anderson)     -             -  53 

38.  Section  through  Part  of  Ovary  of  Adult  Bitch.     (Waldeyer)    -             -  54 

39.  A,  Recently  Ruptured  Graafian  Follicle.    B,  Normal  Graafian  Follicle, 

showing  Stigma.     (Micro-photographs  prepared  by  McConnell 

and  J.  C.  Hirst)         -             -             -                       ,    -             -             -  55 

40.  The  Corpus  Luteum  at  the  End  of  Pregnancy.     (Dalton)        -  -57 

41.  Pelvic  Diaphragm  from  Above.     (Bumm)           -             -             -             -  60 

42.  Pelvic  Diaphragm  from  Below.     (Bumm)           -             -             -             -  61 

43.  Mammary  Gland  during  Lactation.     (Luschka)             -             -             -  65 

44.  Lactating  Breast.     (W.  Williams)                         -             -             -             -  66 

45.  Human  Milk.     (W.  Williams)     -             -             -                          -             -  67 

46.  Human  Colostrum.     (W.  Williams)        ...                           -  67 

47.  Ovum  of  Rabbit.     (Waldeyer)    -                           -                                        -  70 

48.  Ovum  in  Graafian  Follicle.     (Piersol)    -             -             -             -             -  71 

49.  Diagrams  to  show  Fertilisation  of  the  Ovum.     (Selenka)          -             -  72 

50.  Diagrams  showing  Segmentation  of  a  Mammalian  Ovum,  and  the 

Formation  of  the  Blastodermic  Vesicle.     (Allen  Thomson,  after 

Van  Beneden)            -             -            -            -            -            -            -  73 

51.  Embryonic  Area,  showing  Primitive  Streak  and  Groove.     (Quain)     -  74 

52.  Embryonic  Area,  from  Rabbit's  Ovum.     (Kolliker)      -  -  "74 

53.  Sections  through   Embryonic  Area,  showing  the  Formation  of  the 

Mesoblast  on  Each  Side  of  the  Primitive  Groove.     (Heape)         -  75 

54.  Section  through  Medullary  Groove  of  an  Early  Embryo.     (Quain)    -  75 

55.  Sections  showing   Stages  in   Conversion  of  Medullary  Groove  into 

Neural  Canal             -            -            -            -            -            -            -  77 

56.  Diagrammatic  Section  through  Ovum,   showing   the    Neural    Canal 

and  Notochord,  and  also  the  Division  of  the  Mesoblast  into  its 

Outer  Somato-pleural,  and  Inner  Splanchno-pleural  Layers        -  79 

57.  Diagram  to  show  Commencement  of  Formation  of  the  Amnion           -  79 

58.  A  Later  Stage  than  Fig.  57                        -             -             -             -             -  79 

59.  Complete  Formation  of  Amnion  and  Chorion    -             -             -             -  79 

60.  Diagrammatic  Longitudinal  Section  through  Embryo,  showing  the 

Amniotic  Ridges  and  the  Gradual  Closing  in  of  the  Anterior  and 

Posterior  Limiting  Sulci  of  the  Ventral  Aspect  of  the  Embryo     -  80 


LIST  OF  ILLUSTRATIONS  xv 

FIU.  HAGE 

61.  Diagram  to  show  tlie  Formation  of  the  Allantois  as  a  Diverticulum 

from  the  Hind  Gut  of  the  Embryo                           -                           -  82 

62.  A  Later  Stage  than  Fig.  61         -             -             -                                        -  82 

63.  Implantation  of  Ovum  on  the  Decidua.     (Grafspee)   -                           -  83 

64.  Uterus  with   Ovum  at    the   Third   Month  of   Pregnancy.      Sagittal 

Section.     (Bumm)  -             -             -             -             -             -             -  84 

65.  Vertical  Section  through  Decidua  Vera  at  end  of  Third  Month  of 

Pregnancy.     (Bumm)          -             -             -             -             -             -  86 

66.  Section  showing  Chorionic  Villi  extending  into  Decidua  Serotina. 

(Bumm)        --.----•-  88 

67.  Chorionic  Villi  of  a  Five  Weeks' Old  Ovum.     (Bumm)           -             -  91 

68.  Diagrammatic  Representation  of  Portion  of  Placenta.     (Bumm)        -  92 

69.  Diagrammatic  Section  through  Uterine  Wall  and  Placenta.   (Bumm)  93 

70.  Placenta  at  Full  Term,  showing  Superficial  Distribution  of  Blood- 

vessels.    (Minot)     -             -             -             -             -             -             -  94 

71.  Umbilical  Cord,  showing  Vessels.     (Tarnier  and  Chantreuil)              -  96 

72.  Diagrammatic  Representation  of  Foetal  Circulation    -             -             -  100 

73.  Diagrammatic  Representation  of  Foetal  Heart              -             -             -  101 

74.  Early  Human    Ovum — from    Fourteen    to    Twenty-one    Days   Old 

(Natural  Size)          -             -             -             -             -             -             -  104 

75.  Diagrammatic  Representation  of  Increase  of  Size  of  Foetus  from  the 

Third  to  the  Eighth  Week.     (After  Mall)              -             -             -  106 

76.  The    Foetal    Skull,    showing    Accessory    Fontanelle.      (Ribemont- 

•     Dessaignes)               -             -             -             -             -             -             -  112 

77.  The  Foetal  Skull  seen  from  the  Side,  showing  the  Points  from  which 

the  Diameters  are  measured           -             -             -             -             -  113 

78.  The  same  seen  from  the  Side,  showing  Diameters       -             -             -  114 

79.  The  same  seen  from  in  Front    -                           -             -             -             -  115 

80.  The  same  seen  from  Behind      -             -             -                          -             -  115 

81.  The  same  seen  from  Above         -             -                                    •    -  116 

82.  The   Circumferences   of    the    Foetal    Skull    Measured    Round    the 

Different  Diameters.     (From  tracings  of  the  head  of  a  newly- 
born  infant  made  by  Dr.  R.  H.  Kennan)               -             -             -  117 

83.  The  Foetal  Skull  seen  from  the  Side,  showing  the  Different  Regions 

into  which  it  is  mapped  out            -             -             -             -             -  118 

84.  The  Foetal  Ovoid  seen  from  in  Front    -             -             -             -             -  119 

85.  The  Foetus  seen  from  the  Side                -             -             -             -             -  120 

86.  The   Attitude    of    the   Foetus    in    utero,    as    seen   from   in    Front. 

(Bumm)       -.---...  I23 

87.  The  same,  as  seen  from  the  Side.     (Bumm)     -  123 

88.  The  same,  as  seen  from  Behind.     (Bumm)      -  123 

89.  The  Full-term  Foetus  in  the  Uterus       -  124 

90.  Diagram  of  the  Foetus  in  utero  in  the  Early  Months    -                          -  126 

91.  Diagram  to  show  Restraining  Effect  of  the  Shape  of  the  Uterus  on 

the  Position  of  the  Foetus  in  a  Longitudinal  Lie               -             -  126 

92.  Diagram   to   show  Effect   of  Foetal  Movements   in    causing    Head 

Presentation             ---.-..  J28 

93.  Diagram  of  Vertex  Presentation  -  -  -  -  .  131 
•94.  Diagram  of  Face  Presentation  -  -  -  -  -  131 
95.   Diagram  of  Brow  Presentation               -  132 


xvi  LIST  OF  ILLUSTRATIONS 

FIG.  PAGE 

96.  Diagram  of  Anterior  Fontanelle  Presentation  -  -  132 

97.  Diagram  of  Posterior  Fontanelle  Presentation  -  -  -  132 

98.  Diagram  of  '  Position  '  in  Longitudinal  Lie  of  Foetus  -  -  134 

99.  Diagram  of  '  Position  '  in  Transverse  Lie        -  134 

100.  The   Foetus  as   seen    from   Above,    showing   the   Correspondence 

between  the  Antero-posterior  Diameters  of  the  Foetal  Ovoid, 
the  Transverse  Diameters  of  the  Uterus,  and  the  Right  Oblique 

Diameters  of  the  Pelvis    -  -  -  135 

101.  The  Author's  Catgut  Steriliser  .  -  -  .  ^ 

102.  Syphon  Douche  -  -  -  -  -  -  -  158 

103.  Female  Catheter  _.-....  x^g 

104.  Abdominal  Palpation :  The  Fundal  Grip        ...  -  jQy 

105.  The  same :  The  Umbilical  Grip  -  168 

106.  The  same  :  The  First  Pelvic  Grip       -----  169 

107.  The  same  :  The  Second  Pelvic  Grip    -  -  -  -  -  170 

108.  The  Hand  and  the  Foot  of  the  New-born  Infant        -  -  -  174 

109.  Diagram  representing  the  Normal  Ball-valve  Action  of  the  Head, 

and  the  consequent  Slight  Protrusion  of  the  Membranes  into 

the  Vagina  .._.____.     175 

no.  Diagram  representing  the  Failure  of  the  Ball-valve  Action  of  the 
Head,  and  the  consequent  Commencing  Undue  Protrusion  of 
the  Membranes  into  the  Vagina  -  -  -  -  -     176 

in.  Diagram  representing  the  Failure  of  the  Ball- valve  Action  of  the 
Head,  and  the  consequent  Marked  Protrusion  of  the  Mem- 
branes into  the  Vagina     ------     177 

112,  113.  Hegar's  Sign  of  Pregnancy  -----     180 

114.  Internal  Ballottement  -------     181 

115.  Site  of  Maximum  Intensity  of  Foetal  Heart-sounds  in  Vertex  and 

Pelvic  Presentations  ------     186 

116.  Site  of  Maximum   Intensity  of  Fcetal  Heart-sounds  in  Face  and 

Brow  Presentations  ------  187 

117.  Martin's  Pelvimeter  for  External  Measurements        -  -             -  190 

118.  External  Pelvimetry  :  Measuring  External  Conjugate  of  Pelvis        -  191 

119.  The  same  :   Measuring  Transverse  Diameter  of  Outlet          -  -  192 

120.  The  same  :  Measuring  Antero-posterior  Diameter  of  Outlet  -  193 

121.  Internal  Pelvimetry :  Johnson's  Method         ...  -  194 

122.  Effect  of  False  Promontory  at  Junction  of  First  and  Second  Pieces 

of  Sacrum  C,  on  the  True  Conjugate  Diameter  C  V     -  -     195 

123.  The    Effect   of   the    Height   of  the    Promontory  on   the    Relation 

between  the  True  and  the  Oblique  Conjugate  Diameters  -     195 

124.  Internal    Pelvimetry  :    Measuring    Oblique    Conjugate   with    the 

Fingers       --.._—_.._..     196 

125.  The  Effect  of   the  Inclination  of  the  Symphysis  on  the  Relation 

between  the  True  and  the  Oblique  Conjugate  Diameters  -     196 

126.  Effects  of  Alterations  in  Symphysis  of  Thickness  (A),  and  of  Depth 

(B)  on  Relation  between  the  True  and  the  Oblique  Conjugate 
Diameters  .-.._--     xgj 

127.  Skutsch's  Internal  Pelvimeter  -  198 

128.  Internal  Pelvimetry  :  Measuring  Obstetrical  Conjugate  phis  Thick- 

ness of  Symphysis  and  Superjacent  Soft  Parts  -  -  -     199 


LIST  OF  ILLUSTRATIONS  xvii 

FIG.  FAGE 

129.  Internal    Pelvimetry :     Measuring   Thickness    of    Symphysis   and 

Superjacent  Soft  Parts      .--...     200 

130.  The  same  :  Measuring  Transverse  Diameter  of  Brim//«s  Thickness 

of  Lateral  Wall  of  Pelvis  and  Superjacent  Soft  Parts   -  -     201 

131.  The  same:   Measuring  Thickness  of   Lateral  Wall  of  Pelvis  and 

Superjacent  Soft  Parts      ------     201 

132.  Uterine  Muscle  Fibres  ......     2o8 

133.  Sagittal  Mesial   Section   of  a  Patient  who   Died   in   the   Second 

Month  of  Pregnancy.     (Braune)  -  209 

134.  Sagittal  Mesial  Section  of  a  Primipara  who  Died  during  the  Fourth 

Month  of  Pregnancy.     (Waldeyer)  -  -  -  -     210 

135.  Diagram  showing  the  Two  Views  held  regarding  the  Formation  of 

the  Lower  Uterine  Segment.     (After  Dickinson)  -  -     213 

136.  Diagram  showing  Direction  of  Cervical  Axis  before  (A)   and  (B) 

during  Pregnancy.     (Galabin)     -  214 

137.  The  Mammary  Areola  at  the  Third  Month  of  Pregnancy.     (Mont- 

gomery)     --.-.--.     219 

138.  The  Mammary  Areola  at  the  Ninth  Month  of  Pregnancy.     (Mont- 

gomery)     --------     220 

139.  Diagram  of  Os  Uteri  in  a  Nullipara  as  seen  through  a  Speculum     -     237 

140.  Diagram   of  Os  Uteri   in   a  Parous  Woman   as   seen   through   a 

Speculum  --------     238 

141.  The  Height  of  the  Uterus  at  the  Different  Weeks  of  Pregnancy. 

(Dickinson)  -.._--_     241 

142.  Diagram  showing  Method  of  measuring  the  Length  of  the  Foetus 

in  utero  with  Calipers        -..._-     242 

143.  Diagram  showing  the  Approximate  Position  of  the  Retraction  Ring 

(RR)  at  the  Commencement  of  Labour  -  260 

144.  The  Cervix  in  a  Primipara  at  the  Commencement  of  Labour  -     264 
145-147.  The  Taking-up  of  the  Cervix  in  a  Primipara       -             -         264,  265 

148.  The  Cervix  in  a  Multipara  at  the  Commencement  of  Labour  -     266 

149,  150.  The  Taking-up  of  the  Cervix  in  a  Multipara  -         266,  267 

151.  Diagrammatic  Section  of  the  Uterus  after  Prolonged   Labour,  to 

show  the  Position  of  the  Retraction  Ring  -  -  -     269 

152.  The  Muscles  of  the  Pelvic  Floor  shown  at  the  Commencement  of 

Dilatation  by  the  Fcetal  Head.     (Bumm)  -  270 

153.  The  Muscles  of  the  Pelvic  Floor  shown  at  the  Moment  of  Complete 

Dilatation  by  the  Fcetal  Head.     (Bumm)  -  -  -     272 

154.  The  Genital  Canal  in  a  Condition  of  Complete  Dilatation,  as  seen 

after  Mesial  Sagittal  Section.     (Bumm)  -  -  -     273 

155.  Diagram  representing  Effect  of  General  Contents  Pressure  prior  to 

Rupture  of  Membranes     ------     276 

156.  Diagram  representing  Effect  of  General  Contents  Pressure  after 

Rupture  of  Membranes     ------     277 

157.  Diagram  representing  '  Foetal-axis  Pressure  '  -  -  -     278 

158.  Coronal  Section   through   Fcetal  Head  at  the  Site  of   the  Caput 

Succedaneum.     (After  Ribemont-Dessaignes)    -  -  -     279 

159.  The  Separation  of  the  Placenta  :  Schultze's  Mechanism       -  -     280 

160.  The   Expulsion   of    the    Placenta    from   the   Uterus :    Schultze's 

Mechanism  -  -  -  -  -  -  -     281 

b 


xviii  LIST  OF  ILLUSTRATIONS 

mi;.  page 

161.  The  Separation  of  the  Placenta  :  Matthews  Duncan's  Mechanism  -  282 

162.  The   Expulsion   of    the    Placenta    from    the    Uterus :    Matthews 

Duncan's  Mechanism        ......  283 

163.  164.  Profile  of  the  Abdomen  during  the  Third  Stage              -             -  292 

165.  First  Vertex  Presentation,  with  the  Back  in  Front    -             -             -  301 

166.  First  Position  of  the  Vertex,  the  Back  in  Front.     (Farabceuf)          -  301 

167.  The  same,  the  Back  Behind  (Farabceuf )         -  302 

168.  First  Vertex  Presentation,  with  the  Back  Behind      -             -             -  302 

169.  Second  Position  of  the  Vertex,  the  Back  in  Front.     (Farabceuf)       -  303 

170.  Second  Vertex  Presentation,  with  the  Back  in  Front             -             -  304 

171.  Second  Position  of  the  Vertex,  the  Back  Behind.     (Farabceuf)         -  305 

172.  Second  Vertex  Presentation,  with  the  Back  Behind  -             -             -  305 

173.  Diagram  representing  the  Foetus  as  felt  by  Abdominal  Palpation  in 

Vertex  Presentation           ..-_.-  306 

174.  Site  of  Maximum  Intensity  of   Heart-sounds  when    the  Head   is 

flexed.     (Bumm)   -------  307 

175.  The  Mechanism  of  First  Vertex  Presentation              -             -             -  308 

176.  Synclitic  Engagement  of  the  Head     -             -             -             -             -  310 

177.  Posterior  Asynclitism  of  the  Head       -             -             -             -             -  311 

178.  Anterior  Asynclitism  of  the  Head        -----  312 

179.  The  Mechanism  of  First  Vertex  Presentation              -             -             -  313 

180.  First  Vertex  Presentation         -            -            -            -            -            -  314 

181.  Diagram  to  show  the  Method  in  which  Flexion  is  produced  by 

Foetal-Axis  Pressure  acting  upon  the  Head         -             -             -  315 

182.  The  Mechanism  of  First  Vertex  Presentation                            -             -  317 

183.  First  Vertex  Presentation         -             -             -             -             -             -  318 

184,185.  Mechanism  of  First  Vertex  Presentation  -  -         320,321 

186.  Reversed  Rotation  of  the  Head            -             -                          -             -  325 

187.  Posterior  Asynclitism,  or  Naegele's  Obliquity             -                          -  328 

188.  Anterior  Asynclitism,  or  Litzmann's  Obliquity           -             -             -  329 

189.  The  Moulding  of  the  Head  in  the  Vertex  Presentation           -             -  330 
igo.  The  Usual  Moulding  of  the  Head  in  Occipito-posterior  Positions  of 

the  Vertex.     (Galabin)      ------  330 

191.  The  Dorsal  Cross-bed  Position             -                          -  335 

192.  The  Knee-chest  Position           -                          -.'---  336 

193.  An  Extemporised  Trendelenburg's  Position    -  336 

194.  Walcher's  Position       -------  337 

195.  Diagram  showing  the  Effect  of  Walcher's  Position  on  the  Length 

of  the  True  Conjugate.     (Bumm)              ...             -  338 

196.  Diagram  showing  the  Manner  in  which  the  Head  ought  not  to  pass 

through  the  Vulvar  Orifice  ------  342 

197.  Diagram  showing  the  Manner  in  which  the  Head  ought  to  pass 

through  the  Vulvar  Orifice          -----  342 

198.  The  Indirect  Method  of  Preserving  the  Perinseum    -             -             -  343 

199.  Expression  of  the  Placenta  by  the  Dublin  Method    -             -             -  353 

200.  Schimmelbusch's  Chloroform  Mask.   -----  357 

201.  Murphy's  Chloroform  Inhaler              _■.-•_.  358 

202.  First  Face  Presentation,  the  Back  in  Front.     (Farabceuf)     -             -  362 

203.  The  same,  with  the  Back  in  Front      -----  362 

204.  The  same,  the  Back  Behind.     (Farabceuf)      -  363 


LIST  OF  ILLUSTRATIONS  xix 

FIG  I'AGE 

205.  First  Face  Presentation,  with  the  Back  Behind         -                           -  363 

206.  Second  Face  Presentation,  the  Back  in  Front.     (Farabceuf)              -  364 

207.  The  same,  with  the  Back  in  Front      -                                                     -  365 

208.  The  same,  the  Back  Behind.     (Farabceuf)      -                           -             -  366 

209.  The  same,  with  the  Back  Behind         ....             -  368 

210.  Diagram  representing  the  Foetus  as  felt  by  Abdominal  Palpation 

in  Face  Presentation         -             -  369 

211.  Site  of  Maximum  Intensity   of  Heart-Sounds  when   the  Head  is 

extended.  (Bumm)  .■._'.___.  371 
212-215.  The  Mechanism  of  First  Face  Presentation  -  -  372-376 
216,  217.   Reversed  Rotation  of  the  Head   -                                                  377,  378 

218.  The  Moulding  of  the  Head  in  Face  Presentation.     (Budin)               -  379 

219.  Schatz'  Method  of  converting  a  Face  Presentation  into  a  Vertex: 

the  First  Step         -             -             -             -             -             -             -  380 

220.  The  same  :  the  Second  Step     -             -             -             -             -             -  381 

221.  The  same  :  the  Final  Step        ------  382 

222.  Baudelocque's  Method  of  converting  a  Face  Presentation  into  a 

Vertex  :   the  First  Step     ------  383 

223.  The  same :  the  Second  Step     -             -             -             -             -             -  •  384 

224.  The  Playfair-Partridge  Method  of  converting  a  Face  Presentation 

into  a  Vertex          -             -                                                                   -  385 

225.  226.  First  Brow  Presentation  -----  388,  389 

227.  Second  Brow  Presentation       ------  3g0 

228.  The  Mechanism  of  First  Brow  Presentation  -             -                          -  391 

229.  The  Moulding  of  the  Head  in  Brow  Presentation      -             -             -  392 

230.  First  Anterior  Fontanelle  Presentation                                      -             -  395 

231.  First  Posterior  Fontanelle  Presentation           -             -                          -  397 

232.  233.   First  Pelvic  Presentation,  the  Back  in  Front      -  399,  400 

234.  A  Footling  Presentation            __■_-_..  ^01 

235.  First  Pelvic  Presentation,  the  Back  Behind.     (Farabceuf)    -             -  402 

236.  The  same,  with  the  Back  Behind         -  403 

237.  Second  Pelvic  Presentation,  the  Back  in  Front.     (Farabceuf)          -  404 

238.  The  same,  with  the  Back  in  Front       -  405 

239.  The  same,  the  Back  Behind.     (Farabceuf)      -  406 

240.  The  same,  the  Back  Behind     ------  ^0S 

241.  Diagram  representing  the  Fcetus  as  felt  by  Abdominal  Palpation 

in  Pelvic  Presentation      ------  409 

242-244.   The  Mechanism  of  First  Pelvic  Presentation      -  -  411-413 

245.  The  Moulding  of  the  Head  in  Pelvic  Presentation.     (Budin)             -  417 

246.  First  Shoulder  Presentation,  Back  in  Front.     (Farabceuf)   -             -  424 

247.  The  same,  with  the  Back  in  Front       -             -                                        -  425 

248.  The  same,  the  Back  Behind.     (Farabceuf)      -  426 

249.  The  same,  with  the  Back  Behind         -----  427 

250.  Second  Shoulder  Presentation,  the  Back  in  Front.     (Farabceuf)      -  428 

251.  The  same,  with  the  Back  in  Front       -                           -             -             -  429 

252.  The  same,  the  Back  Behind.     (Farabceuf)     -             -             -             -  430 

253.  The  same,  with  the  Back  Behind         -  431 

254.  Diagram  representing  the  Foetus  as  felt  by  Abdominal  Palpation 

in  Shoulder  Presentation               -             -             -             -             -  432 

255.  256.   Spontaneous  Evolution  of  the  Fcetus  in  Shoulder  Presentation  435 

b  2 


xx  LIST  OF  ILLUSTRATIONS 

FIG.  PAGE 

257.  The  Moulding  of  the  Foetus  that  occurs  during  Birth  '  Corpore 

Conduplicato '-------  436 

258.  Diagram  showing  the  Effects  of  Posture  on  a  Shoulder  Presenta- 

tion.    (Bumm)        _-.-..-  437 

259.  Decidual  Endometritis,      x  280.     (Williams)  -  -  -  481 

260.  An  '  Apoplectic  Ovum  '  ......  482 

261.  Endometritis  Decidua  Cystica.     (Breus)         ....  483 

262.  Diagram  showing  the  Formation  of  a  Vesicular  Mole.     (Bumm)      -  489 

263.  Section  of  Hydatidiform  Mole,  showing  Proliferation  of  Syncytium 

and  Langhans'  Cells.      x  75.     (Williams)  -  -  -  491 

264.  Uterus  containing  a  Vesicular  Mole   -----  492 

265.  Malignant   Form   of    Vesicular    Mole,   growing   through   Uterine 

Wall.     (Bumm)     -------  494 

266.  Chorion-Epithelioma,  showing  Alveolar  Arrangement  of  Primary 

Tumour,      x  60.     (Williams)        -----  501 

267.  Chorion-Epithelioma,  showing  Syncytial  Masses  invading  a  Venous 

Channel.     (Williams)        ------  502 

268.  Ovum,  showing  Amniotic  Adhesions  -  -  -  -  -  511 

269.  Normal  (A)  and  Syphilitic  (B)  Chorionic  Villi  teased  out  in  Salt 

Solution,  and  Slightly  Magnified.     (Williams)  -  -  -  512 

270.  Normal  Full-term  Placenta,      x  50.     (Williams)        -  -  -  513 

271.  Syphilitic  Full-term  Placenta,      x  50.     (Williams)     -  -  -  514 

272.  A  Placenta  Succenturiata         ------  519 

273.  A  '  Battledore  '  Placenta  .-,--..  520 

274.  Coiling  of  the  Umbilical  Cord  .....  525 

275.  False  Knots  on  the  Cord  ..-.--  526 

276.  Velamentous  Insertion  of  the  Cord      -----  527 

277.  Incarceration     of     a    Retro-flexed     Pregnant     Uterus.       (Wyder- 

Schwyzer)  -  -  -  -  -  -  -  533 

278.  A  Pendulous  Abdomen  ......  541 

279.  Prolapse  of  the  Hypertrophied  Cervix  at  the  Eighth    Month  of 

Pregnancy.     (Bumm)        ---.--.-  545 

280.  Double  Uterus  and  Vagina.     (Courty)  -  547 

281.  Uterus  Bi-cornis,  with  Double  Vagina.     (Schroeder)  -  -  547 

282.  Uterus  Bi-cornis,  with  Single  Vagina  -  548 

283.  Uterus  Septus  Bi-locularis        ..--..  549 

284.  Uterus  Unicornis  -------  550 

285.  Area  of  Necrosis  in  Eclamptic  Liver,      x  90.     (Williams)     -  -  599 

286.  An  Expelled  Ovum  embedded  in  Thickened  Decidua  -  -  623 

287.  The  Bi-manual  Method  of  expressing  a  Detached  Ovum      -  -  627 

288.  Diagram  of  Tube  and  Ovary,  showing  the  Different  Positions  in 

which  the  Ovum  can  become  implanted  -  -  -  638 

289.  A  Ruptured  Fallopian  Tube    ------  643 

290.  The   Ovum  which    escaped   from    the   Ruptured   Tube  shown  in 

Fig.  289      --------  644 

291.  An  Interstitial  Pregnancy  at  about  the  Fourth  Month  -  -  650 

292.  A  Retro-uterine  Hematocele  formed  by  the  Rupture  of  a  Left-sided 

Tubal  Pregnancy.     (Bumm)         -----  655 

293.  A  Tubal  Abortion.     (Bumm)   ------  657 

294.  Pregnancy  in  the  Rudimentary  Horn  of  a  Two-horned  Uterus        -  658 


LIST  OF  ILLUSTRATIONS  xxi 

FIG.  PAGE 

295.  Diagram  showing  the  Shape  of  the  Cervix  during  and  subsequent 

to  the  Expulsion  of  the  Ovum      -                                                     -  677 

296.  Diagram  showing  Vaginal  Tampon  in  situ      -  689 

297.  A  Sagittal  Section  of  the  Uterus  at  End  of  Third  Month  of  Preg- 

nancy, showing  Reflexal  Placenta.     (Webster)                -             -  693 

29S.  Diagram  showing  Different  Situations  of  the  Placenta           -             -  695 

299.  Central  Placenta  Prsevia.     (Bumm)    -----  696 

300.  A  Marginal  Placenta  Prsevia.     (Ahlfeld)          -  697 

301.  The  Change  of  Shape  that  occurs  in  (A)  the  Presenting  Head,  and 

(B)  the  After-coming  Head,  when  Compressed  by  the  Brim  of 

a  Contracted  Pelvis           -             -             -             -             -             -  731 

302.  Miiller's  Method  of  ascertaining  the  Date  at  which  to  Induce  Labour  736 

303.  304.  The  Generally  Contracted  Non-rachitic  Pelvis  -             -          740,  741 

305.  The  Generally  Contracted  Pelvis.     The  Dwarf  Pelvis           -             -  742 

306.  The  Dwarf  Pelvis          -             -             -             -             -             -  .  743 

307.  The  Flattened  Pelvis.    Rachitic  Flat  Pelvis.    Typical  Minor  Degree  746 

308.  Rachitic  Flat  Pelvis.     Typical  Minor  Degree             -             -             -  747 

309.  The  Flattened  Pelvis.     Rachitic  Flat  Pelvis.     An  Extreme  Degree 

associated    with    Dislocation   of    Left    Sacro-iliac    Joint   and 

Consequent  Slight  Obliquity        .....  748 

310.  The  Rachitic  Flat  Pelvis.     Extreme  Degree               -             -             -  749 

311.  312.  Rachitic  Generally  Contracted  Flat  Pelvis  -  -  754,  755 
313,314.   Pelvis  of  Congenital  Dislocation  of  the  Hips      -             -          756,757 

315.  Oblique  Distortion  of  the  Pelvis.     The  Kypho-scoliotic  Pelvis         -  762 

316.  The  Kypho-scoliotic  Pelvis      -             -                           ...  763 

317.  Oblique  Distortion  of  the  Pelvis.  The  Coxalgic  Pelvis  -  -  764 
31S.  The  Coxalgic  Pelvis  ----...  765 
319    Oblique  Distortion  of  the  Pelvis.     The  Unilateral  Synostotic  or 

Naegele's  Pelvis    -------  766 

320.  Naegele's  Pelvis             -------  757 

321.  Transverse  Contraction  of  the  Pelvis.    Robert's  Pelvis         -             -  770 

322.  Robert's  Pelvis               -------  77! 

323.  Transverse  Contraction  of  the  Pelvis.     The  Kyphotic  Pelvis            -  772 

324.  The  Kyphotic  Pelvis     --.....  773 

325.  A  Case  of  Spondylizema           --....  775 

326.  327.   The  Funnel-shaped  Pelvis             -                                                  776,  777 

328.  The  Compressed  or  Triradiate  Pelvis.     The  Osteo-malacic  Pelvis  -  780 

329.  The  Osteo-malacic  Pelvis         --....  781 

330.  The  Compressed  or  Triradiate  Pelvis.     The  Rachitic  Triradiate, 

or  Pseudo-osteo-malacic  Pelvis    -----  782 

331.  The  Rachitic  Triradiate  Pelvis  .....  783 
332>  333-  The  Spondylolisthetic  Pelvis        ....         786,  787 

334.  Pelvis  Narrowed  by  Osteoid  Tumour  Springing  from  the  Sacrum  -  788 

335.  336.  The  Split  Pelvis    ------         789,  790 

337.  A  Myomatous  Uterus  which  is  Three  Months  Pregnant.     (Bumm)  -  792 

338.  The  Myoma  shown  in  Fig.  337  at  Full  Term.     (Bumm)       -             -  793 

339.  The  Myoma  shown  in  Figs.  337,  338,  during  the  Period  of  Dilata- 

tion.    (Bumm)       ---..-.  795 

340.  A    Large    Subserous  Myoma  impacted   in    Douglas'    Pouch,    and 

Blocking  the  Genital  Canal.     (Bumm)    -  796 


xxii  LIST  OF  ILLUSTRATIONS 

FIG.  PAGE 

341.  A  Large  Ovarian  Cyst  complicating  Pregnancy.     Part  of  the  Cyst 

is  impacted  in  Douglas'  Pouch,  and  prevents  the  Descent  of 

the  Head.     (Bumm)           ...                          -             -  803 

342.  A  Case  of  Sexlets.     (Kerr  and  Cookman)        -            -             ...  809 

343.  Diagram  of  Bi-ovular  Twins    -----             -  810 

344.  Diagram  of  Uni-ovular  Twins,  derived  from  Ovum  with  a  Double 

Nucleus-     --------  811 

345.  The  same,  derived  from  Single  Germinal  Area           -             -             -  812 

346.  Twins  presenting  by  the  Vertex                         ...  813 

347.  Twins  presenting  by  Vertex  and  Breech          -             -             -             -  813 

348.  Twins  presenting  by  Breech  and  Back             -             -             -             -  814 

349.  Twins  lying  transversely           -             -             -             -             -             -  815 

350.  Twins  presenting  by  the  Vertex  and  Breech  as  felt  by  Abdominal 

Palpation  -  '          -             -             -             -             -             -             -  816 

351-355.  Locked  Twins         ------  820-823 

356.  Presentation  of  an  Arm  with  the  Head  -         -             -  826 

357.  Presentation  and  Prolapse  of  the  Umbilical  Cord      -            -            -  830 

358.  Method  of  using  Catheter-repositor     -----  836 

359.  Impacted  Shoulders      -------  842 

360.  A   Fcetus  with    Hydromeningocele    and    Congenital   Absence    of 

Abdominal  Wall    -------  846 

361.  An  Acephalian  Omphalosite    -            -            -            -            -            -  851 

362.  An  Anencephalic  Monster        -            -            -            -            -       '     -  852 

363.  Back  View  of  Anencephalic  Monster  shown  in  Fig.  362        -            -  853 

364.  A  Teratodyme  --------  855 

365.  A  Teradelphian              -             -             -             -             -            .-             -  856 

366.  A  Xiphopagous  Monster            .--...  857 

367.  An  Ischiopagous  Monster        ------  858 

368.  Hsematoma  of  the  Vulva.     (Bumm)    -            -            -             -            -  861 

369.  Bi-manual  Compression   of  the  Uterus   in   Post-partum   Haemor- 

rhage         --------  867 

370.  Hossack's  Canula  for  Intravenous  Infusion    -  872 

371.  The  Canula  introduced  into  the  Median  Vein  just  below  the  Bend 

of  the  Elbow          -             -             -             -             -             -             -  873 

372.  The  Manual  Removal  of  the  Placenta              ....  876 

373.  Diagram  representing  Approximate  Position  of  the  Retraction  Ring 

after  a  Prolonged  Labour.     (Schroeder)                -             -             -  878 

374.  Diagram  to  show  a  Rupture  of  the  Lower  Uterine  Segment  in  con- 

sequence of  the   Impaction  of  a  Hydrocephalic  Head  at  the 

Pelvic  Brim           -            -             -            -                         -            -  880 

375.  Diagrammatic  Representation  of  the  Standing  Out  of  the  Round 

Ligaments  in  Threatened  Rupture  of  the  Uterus.     (Bumm)     -  881 

376.  Nipping  of  the  Anterior  Lip  of  the  Cervix  by  the  Head  in  a  Case  of 

Flat  Pelvis                                       -            -             -        -                -  884 

377.  Complete  Inversion  of  the  Uterus  and  Vagina,  the  Placenta  still 

adherent.     (Bumm)           ------  896 

378.  Puerperal  Endometritis  due  to  Colon  Infection,  showing  Marked 

Development  of  Leucocytic  Wall.     (Williams)-             -             -  914 

379.  Colon'  Bacillus    Endometritis ;    Leucocytic  Wall   not  invaded   by 

Bacteria,      x  800.     (Williams)     -             -             -             -             -  915 


LIST  OF  ILLUSTRATIONS  xxiii 

FIG.  WAGE 

380.  Uterus  removed  from  a  Patient  who  died  of  Acute  Sepsis     -             -  920 

381.  Puerperal  Endometritis  due  to  Streptococcus  Infection,  showing 

Slight  Development  of  Leucocytic  Wall.     (Williams)   -             -  921 

382.  Streptococcic  Endometritis,  showing  Invasion  of  Leucocytic  Wall. 

X  800.     (Williams)            -                           ....  522 

383.  Uterus  removed   from  a  Patient  who  died  of  Mixed  Septic  and 

Saprophytic  Infection       ....-•  924 

384.  Section   through  Thrombosed  Pelvic  Vein,  showing  Streptococci. 

x  800.     (Williams)            ...             -                          -  925 

385.  Martin's  Whole-curved  Needles           -                           ...  956 

386.  Martin's  Needle-holder              -                                                                   -  957 

387.  A  Posterior  Speculum  -             -                                        -  957 

388.  An  American  Forceps  -------  958 

389.  Bossi's  Dilator,  the  Blades  closed        -             -                                        -  95§ 

390.  Bossi's  Dilator,  the  Blades  partly  open                         -                           -  959 

391.  Frommer's  Dilator,  the  Blades  open  -             -                                        -  959 

392.  De  Seigneux's  Dilator  -                                        ....  gcjg 

393.  The  Dilating  Portion  of  the  Blades,  showing  the  Relative  Sizes  of 

Different  Sets         -                                                   ...  960 

394.  Champetier  de  Ribes'  Hydrostatic  Dilator,  and  Forceps  for  insert- 

ing it                                                                 ....  961 

395.  Barnes'  Hydrostatic  Dilator,  and  Syringe  for  filling  it          -             -  961 

396.  The  Different  Stages  in  Harris'  Method  of  Manual  Dilatation  of 

the  Cervix.     (Harris)         ------  963 

397.  Rheinstadter's  Flushing  Curette           _•-.-.  965 

398.  Hegar's  Sharp  Curette              -             -                          -■-■'-  965 

399.  Bozemann's  Double-channelled  Catheter        -             -                           -  966 

400.  Perinseal  and  Vaginal  Lacerations.     A,  Simple  Laceration  of  Peri- 

nasal  Body  ;  B,  Perinasal  Laceration  and  Unilateral  Vaginal 

Laceration.     (Bumm)        -                                                                   -  974 

401.  The  same.     A,  Laceration  of  Perinasum  and  Bilateral  Laceration  of 

the  Vagina;  B,  Laceration  of  Perinasum,  Rectal  Wall,   and 

Vaginal  Wall.     (Bumm)  ------  975 

402.  The  Suture  of  a  Laceration  of  the  Perinasum  and  Vagina.    (Bumm)  976 

403.  404.    The  Suture  of  a   Complete    Laceration   of    the    Perinasum. 

(Bumm)      -------         976,  977 

405.  Forceps  for  Plugging  the  Uterus                                                  -             -  979 

406.  Tamponade  of  the  Uterus        .'-■-.-                         -  980 

407.  Tarnier's  Diagram  showing  Defects  of  Ordinary  Forceps      -             -  984 

408.  Pajot's  Manoeuvre.     (Williams)            ..,..•_-.  985 

409.  Neville's  Axis-traction  Forceps             .....  986 

410.  Milne  Murray's  Axis-traction  Forceps             ...             -  986 

411.  Tarnier's  Axis-traction  Forceps            -             -             -             -             -  987 

412.  The  Introduction  of  the  Lower  Blade  of  the  Forceps                           -  991 

413.  Rotation  of  the  Handle  of  the  Lower  Blade  of  the  Forceps  to  bring 

the  Blade  to  the  Left  Side  of  the  Pelvis                -             -             -  992 

414.  The  Lower  Blade  of  the  Forceps  in  situ           ...             -  993 

415.  The  Introduction  of  the  Upper  Blade  of  the  Forceps                           -  994 

416.  Rotation  of  the  Handle  of  the  Upper  Blade  to  bring  the  Blade  to 

the  Right  Side  of  the  Pelvis          -           .  -             -             -             -  995 


xxiv  LIST  OF  ILLUSTRATIONS 

FIG.  PAGE 

417.  The  Blades  Locked,  and  the  Axis-traction  Apparatus  applied  -     996 

418.  The  Direction  in  which  Traction  is  made  as  the  Head  comes  on  to 

the  Perinasum        -..-...     Qgy 

419.  The  Direction  in  which  Traction  is  made  as  the  Head  is  passing 

through  the  Vulva  ------     998 

420.  The  Relation  of  the  Forceps  to  the  Head  in  a  First  Vertex  Presen- 

tation, with  the  Back  in  Front     -----     999 

421.  The  Relation  of  the  Forceps   to  the  Head  in  a   Second  Vertex 

Presentation,  with  the  Back  in  Front      -..-..   1000 

422.  The    Relation   of   the    Forceps   to   the    Head   in   an    Uncorrected 

Occipito-posterior  Position  of  the  Vertex  -  -  -  1002 

423.  The  Relation  of  the  Forceps  to  the  Head  in  a  Face  Presentation 

after  Forward  Rotation  of  the  Chin         -  1003 

424.  Combined  Version         .-.-.-.  1009 
425-427.  Internal  Version      ------      1011-1014 

428,  429.  The  Extraction  of  the  Pelvic  Pole  of  the  Foetus.      Bringing 

down  a  Leg  -  -  1017,  1018 

430.  The  same.     Traction  on  the  Leg         -  1019 

431.  The  Extraction  of  the  Pelvic  Pole  of  the  Foetus  by  Traction  on  the 

Anterior  Groin      -------  102 1 

432.  The  Extraction  of  the  Pelvic  Pole  of  the  Foetus  by  Traction  on 

Both  Groins  -------  1022 

433.  The  Extraction  of  the  Pelvic  Pole  of  the  Foetus  by  means  of  a 

Gauze  Fillet  applied  over  the  Anterior  Groin     -  -  -   1023 

434.  The  Liberation  of  the  Arms  in  Pelvic  Presentation  -  -  -  1026 

435.  The  Nuchal  Position  of  the  Arm  -  1027 

436.  The  Extraction  of  the  After-coming  Head.     The  Modified  Prague 

Method      --------  1029 

437.  The  same.     Martin's  Method  -  -  -  1031 

438.  The  same.     Smellie's  Method  -  -  -  1033 

439.  The  Extraction  of  the  After-coming  Head  in  which  the  Face  has 

Rotated  Anteriorly  and  the  Chin  has  caught  above  the 
Symphysis  _-__.-.  1035 

440.  Horizontal  Section  through  the  Right  Sacro-iliac  Joint  of  a  Pelvis 

on  which  Symphysiotomy  has  been  performed  -  -  -  1050 

441.  Diagram  of  Pelvic  Brim  showing  the  Gain  in  Space  on  Opening 

the  Symphysis       -------  1051 

442.  Diagram  showing  the  Manner  in  which  the  Head  Bulges  between 

the  separated  Pubic  Bones,  and  the  Relative  Sizes  of  the 
Spheres  which  will  pass  through  before  and  after  Symphy- 
siotomy.    (Farabceuf)        ------  1053 

443.  Farabceuf's  Knife  for  Dividing  the  Symphysis  Pubis  -  -  1054 

444.  Galbiati's  Sickle-shaped  Knife  for  Dividing  the  Symphysis  Pubis    -  1054 

445.  Farabceuf's  Grooved  Sound  for  Protecting  the  Tissues  behind  the 

Symphysis  during  Section  of  the  Joint    -  -  -  -   1055 

446.  Pinard's  Separator  for  Measuring  the  Distance  between  the  Pubic 

Bones  after  Symphysiotomy         .._•-..  1056 

447.  The  Symphysis  Pubis  seen  from  in  Front,  showing  the  Relations  of 

the  Crura  of  the  Clitoris  ------  1057 

448.  Simpson's  Perforator    -------  1061 


LIST  OF  ILLUSTRATIONS  xxv 

FIG.  PAGE 

449.  Braun's  Cranioclast       -------  1061 

450.  Diagram  showing  the  Effect  of  Traction  with  a  Cranioclast  on  a 

Perforated  Head    -------  1062 

451.  A,  Winter's  Modification  of  Auvard's  Combined  Cranioclast  and 

Cephalotribe  ;  B,  Braxton  Hicks'  Cephalotribe  -  -  1063 

452.  Simpson's  Basilyst        -  -  -  1064 
453-456.  The  Performance  of  Craniotomy               -             -             -       1065- 1068 

457.  Braun's  Blunt  Hook  for  Decapitation  -  1071 

458.  Galabin's  Modification  of  Ramsbotham's  Decapitating  Hook  -  1071 

459.  Decapitation  with  Braun's  Blunt  Hook  in  a  Neglected  Shoulder 

Presentation  -------  1072 

460.  A  Tetarelle         ------  .  1087 

461.  The  Soxhlet  Milk  Steriliser      -  -  ^94 

462.  Diagram   showing   the   Actual    Size    of    an   Infant's    Stomach   at 

Different  Periods  -------  1096 

463.  Schultze's  Method  of  Artificial  Respiration  :  Inspiration      -  -  1098 

464.  The  same  :  Expiration  ......  1099 

465.  Marshall  Hall's  Method  of  Artificial  Respiration :  Inspiration  -  1100 

466.  The  same  :  Expiration  ......  hoi 

467.  Double  Cephalhaematoma        -  -  -  -  -  -  1110 


PLATES 


PLATE  I. 

Mesial  Sagittal  Section  of  a  Primipara  who  died  at   Full  Term,   but 

before  the  Commencement  of  Labour.     (Waldeyer)         -     To  face  p.     263 

PLATE  II. 

Mesial   Sagittal    Section  of  a   Primipara   who    died    during   the   First 

Stage.     (Saexinger)  -  -  -  -  -     To  face  p.     267 

PLATE  III. 

Mesial  Sagittal    Section  of   a  Primipara  who  died  during  the  Second 

Stage,  but  before  the  Membranes  ruptured.      (Braun)     -     To  face  p.     271 

PLATE  IV. 
Braun's  Section,  after  the  Removal  of  the  Foetus       -  -     To  face  p.     272 

PLATE  V. 

Mesial    Sagittal    Section  of  a  Woman   who   died  Five   Minutes   after 

Delivery.     (Webster)  -  To  face  p.     441 

PLATE  VI. 

Mesial  Sagittal  Section  of  a  Woman  who   died  Thirty-six  Hours  after 

Delivery.     (Webster)  -  To  face  p.     444 

PLATE  VII. 

Mesial  Sagittal  Section  of  a  Woman  who  died  Sixty-eight  Hours  after 

Delivery.     (Varnier)  ...  -  -     To  face  p.     446 

PLATE   VIII. 

Mesial  Sagittal  Section  of  a  Woman  who  died  Twenty-six  Days  after 

Delivery.     (Varnier)  -..-..     To  face  p.     448 

PLATE   IX. 
Skiagram  of  a  Unilateral  Synostotic  or  Naegele's  Pelvis         -     To  face  p.     766 


PART    I 

OBSTETRICAL   ANATOMY— MATERNAL 
AND   OVULAR 


CHAPTER  I 

THE  ANATOMY  OF  THE  BONY  PELVIS 

The  Pelvic  Bones  :  The  Sacrum  ;  The  Coccyx ;  The  Ossa  Innominata — -The 
Pelvis  as  a  Whole  :  The  Inlet ;  The  Outlet ;  The  Cavity  ;  The  Diameters 
of  the  Pelvis ;  The  External  Measurements  of  the  Pelvis ;  Axis  of  the 
Pelvis  ;  Inclined  Planes  of  the  Pelvis ;  The  Joints  and  Ligaments ;  The 
Obliquity  of  the  Pelvis — Transmission  of  Body-weight  —  Differences 
between  the  Male  and  the  Female  Pelvis — The  Development  of  the 
Pelvis. 

In  both  sexes,  the  pelvis  may  be  regarded  as  a  bony  framework 
for  the  attachment  of  the  muscles  and  ligaments  which  unite  the 
lower  limbs  to  the  trunk,  and  as  an  arch  which  transmits,  in  a 
manner  adapted  to  economize  muscular  energy,  the  weight  of  the 
entire  body  to  the  lower  limbs,  and  thence  to  the  ground.  It  also 
serves  to  protect  the  viscera  contained  within  its  cavity,  and  in 
some  degree  to  support  the  abdominal  viscera.  In  the  female,  it 
has  the  additional  function  of  forming  a  semi-rigid  canal,  through 
which  the  child  must  pass  in  the  process  of  parturition,  and 
associated  with  this  function  there  are  several  important  points 
of  distinction  between  the  male  and  female  pelvis.  It  is  chiefly 
in  relation  to  the  mechanism  of  parturition  that  a  study  of  pelvic 
anatomy  is  of  importance  to  the  obstetrician. 

The  Pelvic  Bones. — The  pelvis  is  made  up  of  four  bones — 
the  sacrum,  the  coccyx,  and  the  two  ossa  innominata.  Above,  it 
is  connected  with  the  vertebral  column  by  the  articulation  of  the 
sacrum  with  the  fifth  lumbar  vertebra,  and  below,  it  is  supported 
upon  the  heads  of  the  femora. 

The  Sacrum.-  — The  sacrum  is  composed  of  three  main  portions : 
— a  central  part  formed  by  the  fusion  of  the  bodies  of  the  five 
sacral  vertebrae ;  and  two  lateral  masses.  The  lateral  masses 
constitute  those  portions  of  the  bone  which  lie  external  to  the 
anterior  sacral  foramina.  They  are  developed  from  three  or  more 
distinct  osseous  centres  on  each  side,  and  are  at  first  separated 
from  the  central  portion  by  a  thin  layer  of  cartilage,  but  become 
completely  fused  with  it  before  the  twenty-fifth  year  of  life.  The 
bone  is  principally  composed  of  cancellous  tissue,  and  is  triangular 
in  shape,  with  its  base  directed  upwards  and  forwards,  and  its 
apex  downwards  and  forwards.     The  anterior  surface  is  smooth, 

1  1  —  2 


4  OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 

concave  from  above  downwards,  and  slightly  so  from  side  to  side, 
and  presents  faint  transverse  ridges  or  depressions  which  mark  the 
original  line  of  separation  between  the  individual  sacral  vertebrae. 


Fig.  i. — Sacrum  and  Coccyx. 

Its  width  at  the  base  is  about  4J  inches,  and  at  the  apex  about 
2  inches.  The  posterior  surface  is  irregular,  presenting  a  median 
ridge  formed  by  the  spines  of  the  sacral  vertebrae,  and  is  bounded 


Fig.  2.- 


-A  Longitudinal  Mesial  Section  through  the  Sacrum 
and  Coccyx. 


on  either  side  by  a  vertical  ridge  composed  of  the  sacral  trans- 
verse processes.  It  is  of  less  extent  than  the  anterior  surface, 
and  is  convex  both  in  the  vertical  and  transverse  directions.  It 
gives  attachment  to  some  of  the  muscles  of  the  back.    The  lateral 


THE  PELVIC  BONES  5 

surface  presents  at  its  upper  part  an  anterior  cartilage-covered 
surface,  which  articulates  with  the  ilium, ";:  and  behind  this  there 
is  a  rough,  irregular  area  for  the  attachment  of  the  posterior 
sacro-iliac  ligaments.  Inferiorly,  the  narrow  margin  which  repre- 
sents this  surface  gives  attachment  to  the  sacro-sciatic  ligaments. 
The  base  of  the  bone  has  the  ordinary  appearance  of  the  upper 
aspect  of  a  lumbar  vertebra,  flanked  on  each  side  by  the 
prominent  alae,  and  the  apex  articulates  with  the  first  bone  of 
the  coccyx. 

The  Coccyx. — The  coccyx  lies  immediately  below  the  sacrum, 
and  continues  the  curve  of  that  bone.  With  the  exception  of  its 
first  piece,  which  possesses  a  well-defined  centrum  and  transverse 
processes,  it  is  represented  by  from  three  to  five  rudimentary  bony 
nodules,  which  rarely  become  united  to  one  another  by  osseous 
union  before  middle  life.  In  consequence  of  this,  the  coccyx  is 
freely  movable  in  a  forward  and  backward  direction  around  the 
end  of  the  sacrum,  and  the  individual  pieces  also  move  upon  one 
another.  Occasionally,  however,  premature  union  of  the  various 
parts  and  of  the  first  part  with  the  sacrum  does  occur,  and  may 
prove  a  source  of  some  difficulty  during  the  expulsion  of  the 
child. 

The  Os  Innominatum.  —  This  bone  is  developed  in  a  bar  of 
cartilage  which  appears  on  each  side  of  the  lower  portion  of  the 
vertebral  column  at  an  early  period  of  foetal  life,  and  which  in 
most  mammalia  bends  round  to  meet  its  fellow  of  the  opposite 
side  in  the  middle  line  in  front.  In  each  bar  of  cartilage,  ossifica- 
tion proceeds  in  such  a  way  as  to  produce  three  distinct  bones — 
the  ilium,  the  ischium,  and  the  os  pubis.  At  birth,  these  are  still 
quite  distinct  from  one  another,  being  united  at  the  bottom  of  the 
acetabulum  by  a  Y-shaped  piece  of  cartilage,  in  which  several 
osseous  centres  appear  at  different  periods  after  birth,  and  finally 
bring  about  the  union  of  the  different  parts  at  about  the  twentieth 
year.  The  complete  bone  is  divided  into  an  upper  and  a  lower 
portion  by  means  of  a  prominent  ridge  situated  on  its  inner 
aspect,  and  called  the  ilio -pectineal  line.  The  portion  of  bone 
above  this  line  is  the  broad  expanded  part  of  the  ilium,  and  is 
called  the  ala  ilii.  It  is  bounded  superiorly  by  a  strong  curved 
margin — the  crista  ilii — which  terminates  in  front  and  behind  in 
the  anterior  superior  and  posterior  superior  iliac  spines  respec- 
tively. The  crest  gives  attachment  to  the  flat  abdominal  muscles, 
which  play  such  an  important  auxiliary  part  to  the  contractions 
of  the  uterus  during  labour,  while  to  the  outer  aspect  of  the  ala 
are  attached  the  gluteal  muscles  which  form  the  principal  mass 

*  The  lateral  articular  surfaces  of  the  sacrum  are  usually  asymmetrical. 
Most  frequently  the  right  surface  is  more  deeply  concave  than  the  left,  and  is 
more  overlapped  by  an  anterior  projecting  lip  of  the  ilium.  The  general 
appearance  suggests  that  more  mutual  moulding  of  sacrum  and  of  ilium  has 
occurred  on  this  side,  and  the  fact  is  of  interest  in  connection  with  the  trans- 
mission of  the  body-weight. 


6  OBSTETRICAL  AN  ATOMY —MATERNAL  AND  OVULAR 

of  the  buttock.  Below  this  line  the  bone  is  principally  formed  by 
the  ischium  and  os  pubis,  between  which  there  exists  anteriorly 
a  wide  foramen — the  thyroid  or  obturator  foramen.  This  is,  in 
the  fresh  state,  filled  in  by  a  firm  membrane,  which  gives  origin 
from  its  inner  aspect  to  the  obturator  internus  muscle  and  from 
its  outer  aspect  to  the  obturator  externus. 

The  Pelvis  as  a  Whole. — The  pelvis  as  a  whole,  formed  by 
the  articulation  of  these  different  bones,  is  divided  into  an  upper 
or  false  pelvis,  and  a  lower  or  true  pelvis,  along  a  plane  passing 
through  the  sacral*  promontory  and  the  ilio-pectineal  lines.  The 
part  which  lies  above  this  plane  belongs  to  the  ..abdomen 
proper,  and  forms  a  considerable  part  of  the  posterior  and  lateral 
boundaries  of  that  cavity.  It  also  affords  support  to  many  of  the 
abdominal  contents.      It  is  formed   on  each    side  by  the  broad 


Fig.  3. — Os  Innominatum. 

expanded  portion  of  the  os  ilii,  covered  in  the  recent  state  by  the 
iliacus  muscle  and  by  the  psoas.  The  latter  muscle  runs  along 
the  inner  border  of  the  iliac  fossa,  just  above  the  ilio-pectineal 
line,  and,  indeed,  slightly  overlaps  it.  The  false  pelvis  is  deficient 
in  front,  the  space  between  the  bones  being  filled  up  by  the 
anterior  abdominal  wall.  The  part  which  lies  below  this  plane  is 
known  as  the  true  pelvis.  It  is  bounded  posteriorly  by  the  sacrum 
and  coccyx,  laterally  by  the  body  of  the  ischium  and  by  a  small 
portion  of  the  ilium,  and  in  front  by  the  ramus  of  the  ischium 
and  by  the  pubis.     It  forms  a  bony  cavity  containing  the  pelvic 

*  The  promontory  of  the  sacrum  is  not  quite  in  the  same  plane  as  the  ilio- 
pectineal  lines  and  their  continuation  along  the  sacral  alae,  but  lies  at  a  slightly- 
higher  level.  The  difference,  however,  is  so  slight  that  for  practical  purposes 
it  may  be  regarded  as  non-existent. 


THE  TRUE  PELVIS  7 

viscera,  and  constitutes  the  firm  boundary  of  the  canal  through 
which  the  child  must  pass  in  parturition.  It  will  be  described 
under  three  headings — the  inlet,  the  outlet,  and  the  cavity. 

The  Pelvic  Inlet. — The  inlet  of  the  pelvis  is  formed  by  the 
boundaries  of  the  plane  which  separates  the  true  from  the  false 
pelvis.  Commencing  in  front,  it  is  bounded  on  each  side  by  the 
symphysis  pubis,  the  crest  and  inner  margin  of  the  horizontal  ramus 
of  the  pubis,  the  ilio-pectineal  eminence,  the  ilio-pectineal  line, 
and  the  anterior  margin  of  the  base  of  the  sacrum.  In  man,  all 
these  points,  with  the  exception  of  the  promontory  of  the  sacrum 
already  referred  to,  are  approximately  situated  on  the  same 
plane,  but  in  other  mammalia  there  is  a  distinct  angle  (ilio-pubic 
angle)  formed  anteriorly  between  the  ilium  and  the  os  pubis  by 
a  bending  upwards  of  the  ramus  of  the  pubis  at  the  ilio-pectineal 
eminence.  In  consequence  of  this,  in  all  mammalia  but  man,  the 
lateral  portion  of  the  boundary  of  the  inlet  lies  below  the  level 
of  a  line  drawn  from  the  symphysis  pubis  to  the  base  of  the 
sacrum.  Owing  to  a  slight  forward  projection  of  the  sacral  pro- 
montory, the  inlet  is  somewhat  heart-shaped. 

The  Pelvic  Outlet. — The  outlet  of  the  pelvis  is  bounded  from 
before  backwards  by  the  symphysis  pubis,  the  lower  margin  of 
the  body  and  descending  ramus  of  the  pubis,  the  ramus  of  the 
ischium,  the  tuber  ischii,  the  great  sacro-sciatic  ligament,  and 
the  tip  of  the  coccyx  on  each  side.  It  is  usually  described  as 
lozenge-shaped,  the  lozenge  being  formed  of  two  triangles  which 
have  a  common  base  represented  by  an  imaginary  line  drawn 
transversely  between  the  tubera  ischii.  The  apex  of  the  posterior 
triangle  is  situated  at  the  tip  of  the  coccyx,  and  that  of  the  anterior 
at  the  lower  margin  of  the  symphysis  pubis.  In  front,  the  under- 
surface  of  the  symphysis  is  rounded  off  by  the  sub-pubic  ligament. 
As  compared  with  the  inlet,  the  outlet  is  obviously  capable  of 
great  variations  in  size,  since  it  is  partially  bounded  by  liga- 
mentous structures  and  partially  by  the  movable  coccyx. 

The  Pelvic  Cavity. — The  cavity  of  the  pelvis  is  the  space  con- 
tained between  the  plane  of  the  inlet  and  the  outlet.  Posteriorly, 
it  is  bounded  by  the  sacrum  and  the  coccyx,  and  is  in  vertical 
depth  about  4^  inches  in  the  female.  Anteriorly,  it  is  bounded 
by  the  posterior  surface  of  the  symphysis  pubis,  and  is  only 
i£  inches  deep.  Laterally,  it  is  bounded  by  the  body  of  the 
ischium,  which  is  3^  inches  deep.  It  is  thus  seen  that  the 
cavity  becomes  progressively  more  shallow  from  behind  forward. 
Posteriorly,  on  each  side  a  large  gap,  the  sciatic  notch,  is  left 
between  the  side  of  the  sacrum  and  the  ischium.  This  space 
is  partially  filled  in  by  the  sciatic  ligaments,  but  superiorly  gives 
egress  to  the  vessels  and  nerves  which  pass  from  the  pelvis  into 
the  gluteal  region,  and  also  to  the  tendon  of  the  pyriformis  muscle. 
On  its  inner  aspect  it  is  covered  over  by  the  parietal  layer  of  pelvic 
fascia.  Anteriorly,  the  obturator  foramen  forms  a  wide  gap  on 
each  side  between  the  ischium  and  pubis. 


8  OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 

On  looking  at  the  pelvis  it  will  be  noticed  that  the  anterior 
boundary  is  flat,  but  that  the  posterior  is  curved,  with  the  con- 
cavity directed  forwards  and  downwards,  and  that  this  curvature 
of  the  sacrum  and  coccyx  gives  the  entire  cavity  a  marked  bend, 
which  in  its  great  extent  is  a  distinguishing  human  characteristic. 
The  difficulty  experienced  in  parturition  by  the  head  of  the  child 
having  to  follow  this  bend  is  somewhat  compensated  for  by  the 
great  shallowness  of  the  cavity,  which  shallowness  forms  another 
characteristic  difference  between  the  human  pelvis  and  that  of 
other  mammalia. 


Fig.  4. — Brim  of  Female  Pelvis,  showing  Diameters. 

P.S.,  Conjugate  diameter;  T.T'.,  transverse  diameter;  R.O.,  right  oblique 
diameter  ;  L.O.,  left  oblique  diameter. 

Diameters  of  the  Pelvis. — An  accurate  idea  of  the  dimensions  of 
the  pelvis  is  best  conveyed  by  stating  the  length  of  certain  lines 
drawn  between  opposing  points  of  the  wall  in  any  given  plane. 
These  lines  are  known  as  the  diameters  of  the  pelvis,  and  in  each 
plane  three  principal  diameters  are  described — the  antero-posterior 
or  conjugate,  the  transverse,  and  the  oblique.  From  an  obstetrical 
standpoint,  the  most  important  planes  to  be  considered  are  those 
of  the  inlet  and  outlet,  as,  speaking  generally,  these  are  more 
contracted  than  the  intervening  ones,  and,  therefore,  afford  a 
greater  obstacle  to  the  passage  of  the  child. 


THE  PELVIC  DIAMETERS  9 

Diameters  of  the  Inlet. — The  antero-posterior  or  conjugate 
diameter  stretches  from  the  promontory  of  the  sacrum  to  the 
upper  margin  of  the  symphysis  pubis,  and  measures,  on  an 
average,  4^-  inches  (11  centimetres).  This  diameter  is  frequently 
called  the  conjugata  vera*  to  distinguish  it  from  the  false  con- 
jugate or  conjugata  diagonalis,  which  is  measured  from  the  sacral 
promontory  to  the  under  margin  of  the  symphysis,  and  which 
exceeds  the  former  by  about  half  an  inch  in  length. 

The  transverse  diameter  is  the  greatest  distance  between  the 
two  ossa  innominata  in  the  coronal  plane,  and  measures  about 
5}  inches  (13  cm.).  It  cuts  the  antero-posterior  diameter  nearer 
to  the  sacrum  than  to  the  pubis,  but  lies  further  forward  in  the 
female  than  in  the  male,  owing  to  the  greater  hollowing  out  of 
the  os  innominatum  in  the  female  sex.  As  compared  with  other 
mammalia,  the  excess  in  length  of  the  transverse  over  the  antero- 
posterior diameter  is  a  striking  human  characteristic. 

The  oblique  diameter  is  drawn  from  the  upper  margin  of  the 
sacro-iliac  joint  to  the  inner  aspect  of  the  opposite  os  innominatum 
at  the  level  of  the  ilio-pectineal  eminence.  The  right  oblique 
diameter  commences  at  the  right  sacro-iliac  joint,  and  extends 
forwards  and  to  the  left ;  the  left  oblique  diameter,  commencing 
at  the  left  sacro-iliac  joint,  ends  at  the  right  ilio-pectineal  eminence. 
Each  of  these  diameters  measures  about  5  inches  (12-5  cm.),  but  it 
is  rare  to  find  them  absolutely  equal  in  length,  the  right,  perhaps, 
being  the  longer  in  the  majority  of  individuals. 

The  oblique  diameter,  as  above  described,  is  anatomically 
convenient,  since  it  is  drawn  between  two  easily  determined 
points  of  the  pelvis  ;  but  since  it  cuts  the  conjugate  diameter 
nearer  to  the  promontory  than  to  the  symphysis,  it  does  not 
accurately  represent  the  central  oblique  diameter  in  which  the 
head  of  the  child  engages.  The  true  central  oblique  diameter 
measures  slightly  under  5  inches,  and  is  indicated  by  a  line  drawn 
from  a  point  a  finger's  breadth  in  front  of  the  ilio-pectineal 
eminence  backwards  through  the  centre  of  the  conjugata  vera 
to  cut  the  pelvic  brim  slightly  anterior  to  the  sacro-iliac 
articulation. 

Another  measurement  is  also  usually  given  in  describing  the 
pelvic  brim,  and  is  called  the  sacro-cotyloid.  It  extends  from  the 
sacral  promontory  to  a  point  on  the  brim  corresponding  to  the 
upper  margin  of  the  acetabulum.  It  measures  about  3f  inches 
(8J-  centimetres),  and  is  of  value  in  defining  the  extent  of  the 
posterior  concavity  of  the  pelvis  at  each  side. 

*  A  distinction  is  sometimes  drawn  between  the  conjugata  vera  and  the 
obstetrical  conjugate,  the  latter  being  the  line  drawn  from  the  promontory  of 
the  sacrum  to  the  nearest  point  of  the  symphysis  pubis.  This  distinction  is 
of  some  importance  in  those  pelves  in  which  there  is  a  well-developed  eleva- 
tion on  the  posterior  aspect  of  the  upper  part  of  the  symphysis  (retro-pubic 
eminence) ;  but  in  most  pelves,  in  which  this  eminence  is  small,  the  obstetrical 
may  be  regarded  as  identical  with  the  true  conjugate. 


io  OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 

The  lengths  of  the  various  diameters  of  the  brim,  as  given 
above,  are  measured  on  the  macerated  pelvis,  and  it  must,  conse- 
quently, be  remembered  that  during  life  a  small  amount  must  be 
deducted  owing  to  the  presence  of  the  soft  parts.  This  remark 
is  especially  true  in  relation  to  the  transverse  diameter,  which  is 
diminished  by  at  least  half  an  inch  by  the  overlapping  of  the 
psoas  muscles  on  each  side,  in  consequence  of  which  the  oblique 
diameter  of  the  brim  during  life  comes  to  be  the  longest  of  the 
three  principal  diameters. 

The  circumference  of  the  brim  measures,  on  an  average,  from 
1 6  to  17  inches  (40  to  43  centimetres)  in  the  macerated  pelvis. 

Diameters  of  the  Outlet. — The  antero- posterior  diameter  of  the 
outlet  extends  from  the  tip  of  the  coccyx  to  the  lower  margin  of 


Fig.  5.— Outlet  of  Pelvis,  showing  Diameters. 


the  symphysis  pubis.  It  measures  3!  inches  (9-5  centimetres), 
but  can  be  increased  by  nearly  an  inch  by  extension  of  the 
coccyx,  so  that  when  that  bone  is  bent  backwards  it  attains  a 
length  of  4f  inches  (11*5  centimetres). 

The  transverse  diameter,  4I  inches  (11  centimetres)  in  length, 
is  measured  between  the  widest  parts  of  the  tubera  ischii,  below 
and  in  front  of  the  ischial  spines  (pre-epineux).  The  distance 
between  the  spines  themselves  (inter -epineux)  is  about  half  an 
inch  less.  The  former  measurement  is,  however,  much  the  more 
important  in  normal  pelves,  since  the  head  of  the  child  passes 
downwards  in  front  of,  rather  than  between,  the  spines  of  the 
ischia.  The  presence  of  the  obturator  internus  muscle  causes 
some  diminution  in  the  transverse  diameter  of  the  outlet  during 
life. 


THE  PELVIC  DIAMETERS  n 

The  oblique  diameter  of  the  outlet  is  not  of  much  importance. 
It  is  drawn  between  the  middle  of  the  inferior  border  of  one  great 
sacro-sciatic  ligament  to  the  junction  of  the  rami  of  the  ischium 
and  pubis  on  the  opposite  side.  It  measures  about  4;  inches 
(11  centimetres),  but  is  capable  of  considerable  elongation  due  to 
stretching  of  the  sacro-sciatic  ligament.  The  circumference  of 
the  outlet  measures  about  134  inches  (34  cm.),  and  is  capable  of 
considerable  increase  from  the  effects  of  a  dilating  force. 

Diameters  of  the  Cavity. — Within  the  cavity  itself  two  planes 
may  be  taken  as  representative,  and  since  they  mark  respectively 
the  place  of  greatest  and  of  least  pelvic  circumference,  they  may 
be  called  respectively  the  plane  of  greatest  expansion  and  the 
plane  of  greatest  contraction. 

The  plane  of  greatest  expansion  lies  between  the  mid-point  of 
the  posterior  surface  of  the  symphysis  and  the  junction  of  the 
bodies  of  the  second  and  third  sacral  vertebrae.  It  passes  across 
the  ischium  at  the  middle  of  the  inner  surface  of  the  acetabulum. 
The  conjugate  diameter  here  measures  nearly  5  inches  (12-5  cen- 
timetres), and  the  transverse  4f  inches  (12  cm.). 

The  plane  of  greatest  contraction  is  contained  between  the 
sacro-coccygeal  joint  and  the  junction  of  the  middle  and  lower 
third  of  the  symphysis.  Included  within  it  are  the  ischial  spines. 
The  conjugate  here  measures  4A  inches  (10-5  centimetres),  and 
the  transverse  4  inches  only  (10  cm.).  This  plane  obviously  forms 
the  true  obstetrical  outlet  of  the  pelvis. 

The  above  measurements  may  be  summarized  in  the  following 
table  : — 


When  these  figures  are  examined,  it  is  seen  that  the  con- 
jugate diameter  becomes  considerably  increased  in  length  imme- 
diately beneath  the  sacral  promontory,  on  account  of  the  vertical 
concavity  of  the  sacrum.  This  increased  length  it  retains  till  the 
sacro-coccygeal  joint  is  reached,  where  it  becomes  somewhat 
suddenly  narrowed  ;  but,  at  the  anatomical  outlet  it  has  more 
than  regained  its  original  length,  on  account  of  the  mobility  of  the 


12         OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 

coccyx.  The  transverse  diameter,  on  the  contrary,  becomes  pro- 
gressively smaller  from  above  downwards,  and  thus  gives  to  the 
whole  pelvis  a  slightly  funnel-shaped  appearance.  The  only  really 
important  oblique  measurement  is  that  of  the  brim,  as  elsewhere 
one  of  its  boundaries  is  formed  by  soft  parts,  which  render  it 
capable  of  great  expansion  under  pressure.  The  changes  in  rela- 
tive length  of  the  conjugate  and  transverse  diameters  in  passing 
through  the  pelvic  cylinder  are  probably  of  prime  importance  in 
determining  the  course  which  the  head  of  the  child  takes.  At  the 
inlet  least  resistance  is  experienced  in  the  transverse  or  oblique 
diameter,  and  consequently  the  head  of  the  child  enters  in  this 
direction.      As   it   passes   downwards,    however,    the   transverse 


Fig.  6. — Front  View  of  Pelvis. 
CC\  Iliac  crests  ;  SS',  anterior  superior  iliac  spines  ;  TT',  great  trochanters. 


resistance  increases,  while  the  antero-posterior  diminishes,  not 
only  on  account  of  the  greater  length  of  the  conjugate  diameter, 
but  also  owing  to  the  relative  shallowness  of  the  anterior  boundary 
of  this  diameter,  and  hence  the  head  of  the  child  turns  round  and 
passes  along  the  direction  of  least  resistance. 

The  preceding  pelvic  measurements  must  be  regarded  as  being 
merely  the  average  of  a  large  number  of  cases,  since,  as  has  been 
already  stated,  they  are  subject  to  great  individual  differences, 
which  depend  partly,  at  any  rate,  on  the  general  size  and  develop- 
ment of  the  body  as  a  whole.  There  are,  moreover,  marked  racial 
differences,  and  it  has  been  shown  that  there  is  a  coincidence 


THE  PELVIC  AXIS  13 

between  the  prevailing  form  of  the  fcetal  skull  and  the  shape  of 
the  pelvis.  In  the  lower  races,  the  ratio  between  the  length  of  the 
conjugate  and  transverse  diameters  of  the  brim  may  vary  widely 
from  that  given  above,  and  the  conjugate  diameter  may  equal, 
or  even  exceed,  the  transverse. 

External  Measurements  of  the  Pelvis. — In  addition  to  the  internal 
diameters  of  the  true  pelvis,  there  are  certain  external  measure- 
ments of  both  the  true  and  the  false  pelvis  which  are  of  consider- 
able importance,  inasmuch  as  they  can  at  all  times  be  readily 
determined  during  life,  and  thus  supply  an  easy  mode  of  diagnos- 
ing the  more  pronounced  forms  of  pelvic  deformity.  The  more 
important  are  as  follows  : — 

(1)  The  inter-spinous  distance— i.e.,  the  distance  between  the  two 
anterior  superior  iliac  spines.  This  measures,  as  a  rule,  about 
10J  inches  (26-5  centimetres),  and  is  always  in  normal  pelves  less 
than  the  distance  between  the  iliac  crests. 

(2)  The  inter-cristal  distance — i.e.,  the  distance  between  the 
widest  parts  of  the  iliac  crests.  This  measures  from  11  to 
1 1  J-  inches  (28  to  29  centimetres). 

(3)  The  external  conjugate  diameter,  measured  from  the  spinous 
process  of  the  last  lumbar  vertebra  to  the  upper  margin  of  the 
symphysis  pubis,  averages  8  inches  (20  centimetres). 

(4)  The  inter-trochanteric  distance,  taken  between  the  summits 
of  the  great  trochanters,  measures  12^  inches  (31  centimetres). 

(5)  The  distance  between  the  posterior  superior  iliac  spines  is 
about  3^  inches  (9  centimetres). 

Axis  of  the  Pelvis. — There  is  considerable  difficulty  in  defining 
the  exact  axis  of  the  pelvis,  since  the  pelvic  cavity,  though 
approaching  to  the  form  of  a  curved  cylinder,  is  very  irregular ; 
and  it  may  at  once  be  stated  that  the  mode  of  determining  the 
axis  which  is  given  below  is  not  altogether  accurate.  It,  how- 
ever, defines  with  considerable  precision  the  path  along  which 
the  head  of  the  child  moves  during  parturition. 

The  axis  of  any  given  plane  of  the  pelvis  is  a  line  drawn  per- 
pendicularly to  it  at  its  central  point,  and,  equidistant  from  every 
part  of  its  circumference,  assuming  the  plane  to  be  the  section  of 
a  sphere.  Since  it  is  impossible  to  determine  the  exact  centre  of 
any  plane,  however,  it  becomes  necessary  to  adopt  as  a  working 
centre  the  point  of  bisection  of  some  given  line  lying  in  the  plane. 
At  the  brim,  the  middle  of  the  conjugata  vera  is  selected.  A 
line  drawn  at  right  angles  to  it  represents  the  axis  of  the  brim, 
and  would,  if  produced,  cut  the  abdominal  wall  at  the  level  of  the 
umbilicus  above,  and  below  would  strike  the  inferior  extremity 
of  the  coccyx.  Now,  the  symphysis  pubis  may  be  regarded  as 
being  parallel  to  the  upper  two  sacral  vertebrae,  and  is  nearly  of 
the  same  vertical  depth  ;  and  therefore  the  part  of  the  pelvic 
cavity  which  is  enclosed  between  the  plane  of  the  brim  and  a 
plane  extending  between  the  lower  margin  of  the  symphysis  and 
the  junction  of  the   second   and  third  sacral  vertebrae  may  be 


i4         OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 

looked  upon  as  forming  a  short  cylinder,  whose  axis  will  be 
identical  with  the  axis  of  the  plane  of  the  brim.  The  axis  of 
every  plane  in  this  cylinder  will  then  be  represented  by  that 
portion  of  the  prolonged  axis  of  the  brim  which  is  contained 
within  the  cylinder. 

The  axis  of  the  outlet  is  determined  in  a  similar  manner  to  that 
of  the  brim,  by  drawing  a  line  at  right  angles  to  the  mid-point  of 
its  conjugate  diameter.  This  line,  when  prolonged  upwards,  strikes 
the  sacral  promontory  when  the  coccyx  is  in  its  normal  position, 
but  when  the  coccyx  is  extended  it  meets  the  sacrum  at  a  much 
lower  level. 

The  axes  of  the  upper  portion  of  the  pelvis  and  of  the  outlet  are 
thus  readily  determined.  The  axis  of  the  intermediate  portion 
will  be  represented  by  joining  the  central  points  of  a  series  of 
closely  succeeding  planes  contained  within  it,  and  is  best  deter- 


Fig.  7. — Diagram  to  show  the  Method  of  Determining  the 
Pelvic  Axis.     (For  description,  see  text.) 

mined  as  follows  : — Prolong  the  conjugate  diameters  of  the  inlet 
and  of  the  outlet  till  they  meet  anteriorly,  and  from  the  point  of 
intersection  draw  a  series  of  lines  to  the  sacrum  and  coccyx  below 
the  second  sacral  vertebra.  Bisect  that  portion  of  each  of  these 
lines  which  is  contained  between  the  anterior  and  posterior  pelvic 
walls,  and  join  the  points  of  bisection  to  one  another.  A  curved 
line  is  thus  drawn,  the  extremities  of  which  are  to  be  joined  to 
the  centre  of  the  outlet  below  and  to  the  axis  of  the  upper  part  of 
the  pelvis  above,  when  the  complete  line  will  represent  the  axis. 
This  line  is,  to  quote  Ward,"  '  a  more  or  less  irregular  parabolic 
curve,  the  concavity  of  which  is  directed  forwards,  passing  from 
the  fixed  axis  of  the  brim,  and  movable  forwards  at  its  inferior 
extremity,  with  the  movable  axis  of  the  outlet  with  which  it 
corresponds  below.'     It  is  directed  at  first  backwards  and  down- 

*  Todd's  '  Cyclopaedia  of  Anatomy  and  Physiology,'  vol.  v.,  p.  134  et  seq. 


THE  PELVIC  JOINTS  AND  LIGAMENTS 


15 


wards,    then    directly    downwards,    and,    finally,    forwards    and 
downwards. 

Inclined  Planes  of  the  Pelvis. — The  cavity  of  the  true  pelvis 
is  roughly  divisible  into  two  segments — an  antero-inferior  and 
a  postero-superior.  The  dividing-line  between  these  two  parts 
is  formed  by  a  faint  ridge  of  bone  which  extends  on  the  inner 
surface  of  each  os  innominatum,  from  the  spine  of  the  ischium 
upwards  and  forwards  to  the  upper  portion  of  the  obturator 
foramen.  The  parts  of  the  pelvic  wall  which  lie  anterior  to  this 
ridge  are  known  as  the  anterior  inclined  planes  of  the  pelvis 
because  they  slope  downwards  and  forwards  to  the  sub-pubic 
arch  ;  the  portions'  of  the  wall  posterior  to  the  ridge  are  called 


Fig.  8. — Lateral  View  of  Interior  of  Pelvis,  showing  the  Inclined 
Planes  and  the  Sacro-sciatic  Ligaments.  The  Normal  Obliquity 
is  also  represented.     (Naegele.) 


the  posterior  inclined  planes,  and  slope  backwards  and  downwards 
towards  the  concavity  of  the  sacrum.  These  planes  are  supposed 
to  help  in  determining  the  different  rotations  of  the  fcetal  head 
which  occur  during  parturition,  but  it  is  probable  that  their 
importance  has  been  exaggerated. 

Joints  and  Ligaments  of  the  Pelvis  —  Sacvo-iliac  Joint.  —  The 
sacrum  articulates  on  each  side  with  the  posterior  portion  of  the 
inner  surface  of  the  ilium,  forming  the  sacro-iliac  joint.  The 
opposed  surfaces  of  both  bones  are  covered  with  a  thin  layer  of 
hyaline  cartilage,  and  are  somewhat  irregular.  These  cartilaginous 
plates  are,  usually  in  the  male,  and  in  both  sexes  in  old  age, 
directly  connected  together  by  bands  of  fibrous  tissue,  and  hence 
the  common  application  of  the  term  'synchondrosis'  to  the  articula- 


1 6 


OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 


tion.  In  young  females,  however,  and  especially  towards  the 
end  of  pregnancy,  a  distinct  joint  cavity  exists,  and  is  surrounded 
by  a  delicate  synovial  membrane.  In  front  of  the  joint,  a  weak 
and  unimportant  ligament,  called  the  anterior  sacro-iliac,  stretches 
between  the  pelvic  surfaces  of  the  ilium  and  the  sacrum,  and  serves 


Fig.  9. — Section  through  the  Left  Sacro-iliac  Articulation. 
(Luschka.) 

to  round  off  the  irregularity  of  the  interior  of  the  pelvis  caused 
by  the  articulation.  On  the  posterior  aspect  of  the  joint,  the 
posterior  sacro-iliac  ligament,  composed  of  stout  bundles  of  fibrous 
tissue,  stretches   between  the   rough    surfaces  of  the  ilium  and 


Fig.  io. — Section  through  Sacro-iliac  Joint  in  a  Fcetal  Pelvis,  showing 
the  Attachment  of  the  Posterior  Sacro-iliac  Ligament. 

The  lateral  portion  of  the  sacrum  is  also  seen  separated  from  the  remainder 
of  the  bone  by  cartilage.     (Farabceuf.) 


the  sacrum  which  lie  behind  the  articular  surfaces.  Many  of  these 
fibres  are  directed  downwards  and  inwards  from  the  ilium,  and 
one  band  in  particular  (the  oblique  sacro-iliac  ligament)  passes 
from  the  posterior  superior  iliac  spine  to  the  transverse  processes 
of   the  second  and  third    sacral  vertebrae.     Above,    the  joint  is 


THE  PELVIC  JOINTS 


17 


covered  over  by  a  few  transverse  fibres  continuous  with  the 
lumbo-sacral  ligament,  and  below  it  is  closed  in  by  the  superior 
attachment  of  the  sacro-sciatic  ligaments. 

S aero -coccygeal  and  Intev-coccygeal  Joints. — The  articulation  of  the 
sacrum  and  the  coccyx  is  similar  to  the  joints  found  elsewhere 
between  the  bodies  of  the  vertebrae,  but,  as  a  rule,  allows  of  much 
freer  movement.  According  to  Luschka,  there  is  a  definite 
synovial  membrane :;:  present  in  the  intervertebral  disc,  and  this 
enables  the  coccyx  to  move  backwards  and  forwards  freely  upon 
the  apex  of  the  sacrum.  This  movement  is  normally  limited  by 
the  attachment  of  the  sacro-sciatic  ligaments  to  the  side  of  the 
coccyx,  and  the  relaxation  of  these  ligaments,  which  takes  place 
towards  the  end  of  gestation,  greatly  increases  the  mobility  of  the 
bone.  The  transverse  processes  and  cornua  of  the  first  coccygeal 
vertebra  are  also  connected  to  the  sacrum  by  short  ligaments. 


Fig.  11. — Transverse  Section  through  Symphysis  Pubis,  showing  the 
Anterior  Pubic  Ligament  and  the  Synovial  Cavity  in  the  Inter- 
articular  Disc.     (Lusk.) 


The  bony  nodules  of  the  coccyx  are  united  to  one  another  by 
discs  of  fibro-cartilage  and  by  anterior  and  posterior  ligaments. 

Lumbo-sacval  Articulation. — The  base  of  the  sacrum  articulates 
with  the  under-surface  of  the  body  of  the  fifth  lumbar  vertebra, 
forming  with  it  a  very  distinct  angle  projecting  forwards,  which  is 
called  the  sacro-vertebral  angle  or  sacral  promontory.  In  addi- 
tion to  the  normal  ligaments  of  the  vertebral  column — namely,  the 
intervertebral  disc,  the  anterior  and  posterior  common  ligaments, 
and  the  ligamenta  subflava — there  are  two  accessory  ligaments  on 
each  side  belonging  to  this  articulation,  which  from  their  points 
of  attachment  are  called  respectively  the  lumbo-sacval  and  ilio- 
lumbar ligaments.  The  former  of  these  is  fan-shaped,  and  passes 
from  the  lower  border  of  the  transverse  process  of  the  fifth 
lumbar  vertebra  to  the  ala  of  the  sacrum.     The  ilio-lumbar  passes 

*  Sometimes  the  synovial  cavity  is  very  distinct,  and  is  co-extensive  with 
the  articulating  surfaces  of  the  bones. 

2 


18         OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 

from  the  tip  of  the  transverse  process  of  the  same  vertebra  back- 
wards and  outwards  to  the  posterior  part  of  the  iliac  crest. 

Symphysis  Pubis.—  The  bodies  of  the  two  pubic  bones  articulate 
with  one  another  by  their  inner  surfaces  closing  the  pelvic  ring 
anteriorly,  and  forming  a  joint  known  as  the  symphysis  pubis. 
The  opposed  bony  surfaces  are  each  covered  with  a  thin  layer  of 
hyaline  cartilage,  between  which  there  pass  strong  bands  of 
fibro-cartilage,  and  among  these,  at  the  upper  and  posterior  part, 
a  small  synovial  cavity  can  occasionally  be  demonstrated. 

On  the  anterior  and  posterior  surfaces  of  the  articulation,  there 
are  present  ligaments  the  fibres  of  which  pass  transversely.     Of 


Fig.   12. 


Lateral  View  of  Exterior  of  Pelvis,  showing  Pelvic 
Obliquity  and  the  Sciatic  Ligaments. 


these  two  ligaments,  the  anterior  is  much  the  stronger,  and  is 
partially  blended  with  the  lower  tendinous  fibres  of  the  rectus 
abdominis  muscle.  A  weak  supra-pubic  ligament  unites  ■  the 
bones  above,  and  below  there  is  a  strong  sub-pubic  ligament 
which  in  the  middle  line  is  triangular  in  vertical  section,  and 
rounds  off  the  inferior  aspect  of  the  joint.  Its  fibres  extend  for 
a  considerable  distance  downwards  on  the  rami  of  the  pubis  and 
ischium. 

The  Sacro-sciatic  Ligaments. — The  great  sacro-sciatic  ligament 
bounds  the  lower  portion  of  the  pelvic  cavity  on  its  postero- 
lateral aspect,  and  partially  fills  up  the  gap  which  exists  between 


THE  SACRO-SCIATIC  LIGAMENTS 


19 


the  side  of  the  sacrum  and  the  posterior  border  of  the  ischium. 
Above,  it  is  attached  by  a  wide  border  to  the  posterior  inferior 
iliac  spine  and  to  the  side  of  the  sacrum  and  coccyx.  Below,  it  is 
narrower,  and  gains  attachment  to  the  inner  lip  of  the  tuber 
ischii,  sending  forwards  a  prolongation,  known  as  the  falciform 
process,  on  the  inner  side  of  the  ramus  of  the  ischium,  which 
blends  above  with  the  lower  margin  of  the  sub-pubic  ligament. 
The  small  sacro-sciatic  ligament  is  triangular  in  shape,  and  lies 


Jnternat  purUe 
Artery 


Fig.   13. — Outlet  of  Pelvis,  showing  Ligaments.     (Kelly.) 


on  a  plane  anterior  to  the  great  sacro-sciatic  ligament.  It  is 
attached  above  by  its  base  to  the  side  of  the  sacrum  and 
coccyx,  and  below  by  its  apex  to  the  spine  of  the  ischium.  These 
ligaments  are  normally  quite  tense,  and  serve  to  limit  the 
independent  backward  movement  of  the  coccyx  upon  the  sacrum, 
and  also  to  restrain  the  movement  of  the  sacrum  around  its 
transverse  axis. 


20  OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 

Obliquity  of  the  Pelvis." — In  most  of  the  lower  mammalia,  the 
plane  of  the  pelvic  brim  is  placed  almost  at  right  angles  to  the 
long  axis  of  the  body,  and  for  long  it  was  thought  that  the  same 
relation  existed  in  man.  In  fact,  it  was  supposed  that  when  man 
assumed  the  erect  position  the  pelvis  swung  round  through  an 
angle  of  go°  upon  the  heads  of  the  femora,  and  carried  the  trunk 
with  it.  That  this  relation  does  not  exist  was  first  demonstrated 
by  Naegele,t  and  since  his  researches  it  has  been  known  that  the 


Fig. 


-The  Inclination  of  the  Pelvis. 


plane  of  the  pelvic  brim  forms  an  obtuse  angle,  opening  upwards, 
with  the  body  axis,  and  that  man  has  become  erect  partly  by 
the  swinging  round  of  his  pelvis,  which,  however,  is  prevented 
from  passing  through   an  angle  of  more  than   300  by  the  ilio- 

*  The  following  remarks  upon  the  inclination  of  the  pelvis  refer  entirely  to 
the  position  which  it  occupies  when  the  individual  is  standing  erect.  The 
inclination  will  obviously  vary  with  change  of  position  of  the  body. 

j  Naegele,  '  Das  Weibliche  Becken. '     1825. 


THE  OBLIQUITY  OF  THE  PELVIS  21 

femoral  ligaments,  and  partly  by  the  development  of  curvatures 
in  his  vertebral  column. 

The  angle  formed  by  the  plane  of  the  pelvic  brim  with  the 
plane  passing  through  the  horizon  is  on  an  average  about  6o° 
(1500  with  the  body  axis),  but  varies  somewhat  in  different 
individuals,  and  is  less  in  the  female  than  in  the  male.  It 
varies  also  with  changes  in  the  position  of  the  lower  limbs  and 
with  variations  in  the  position  of  the  centre  of  gravity  of  the 
body.  In  fact,  any  cause  which  tends  to  relax  the  ilio-femoral 
ligaments  will  also  produce  a  diminution  in  the  obliquity. 
Normally,  these  ligaments  are  tightly  stretched,  owing  to  the 
fact  that  the  centre  of  gravity  of  the  body  lies  slightly  posterior 
to  the  acetabula  ;  but  if  the  centre  of  gravity  of  the  body  becomes 
shifted  forwards,  as,  for  example,  occurs  in  pregnancy,  the  liga- 
ments are  relaxed  and  the  obliquity  becomes  somewhat  diminished. 


Fig.   15. — Diagram  showing  the  Pelvic  Obliquity. 


The  extent  of  the  normal  inclination  of  the  pelvic  brim  will  be 
more  fully  appreciated  by  stating  that,  in  the  erect  posture,  the 
sacral  promontory  is  placed  at  a  level  3^  inches  above  the  level 
of  the  upper  margin  of  the  symphysis. 

Owing  to  the  great  depth  and  curvature  of  the  posterior  pelvic 
wall  as  compared  with  the  anterior,  the  plane  of  the  pelvic  outlet 
is  not  parallel  with  that  of  the  inlet,  and  its  inclination  is  there- 
fore not  the  same.  If  both  planes  were  prolonged  forwards  they 
would  meet  in  front,  about  one  and  a  half  inches  anterior  to, 
and  slightly  below,  the  symphysis  pubis.  The  tip  of  the  coccyx 
lies  about  half  an  inch  above  the  lower  margin  of  the  symphysis, 
and  the  line  joining  these  two  points,  which  is  taken  as  repre- 
senting the  plane  of  the  outlet,  forms  with  the  horizonal  plane 
an  angle  of  io°  or  n°.  When  the  coccyx  is  extended,  this  angle 
is  diminished,  and  the  conjugate  diameter  of  the  outlet  may  then 
coincide  with  the  horizon. 


22  OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 

Transmission  of  the  Body-weight.  —  Considered  as  the 
medium  through  which  the  body-weight  is  transmitted  to  the 
lower  limbs,  the  pelvis  may  be  regarded  as  being  composed  of  a 
posterior  and  an  anterior  arch. 


Fig.    i  6. 


-Diagram  to  illustrate  Description  of  the  Transmission  of 
the  Body-weight. 


The  posterior  arch  constitutes  that  portion  which  lies  behind 
the  acetabula,  and  is  the  only  portion  which  is  directly  concerned 
in  supporting  the  weight  of  the  trunk.  This  weight  is  transmitted 
differently,  according  as  the  individual  is  in  the  standing  or  sitting 


Fig.  17. — Diagram  to  show  the  Variations  in  the  Amount  of  the 
Body-weight  transmitted  along  the  Different  Planes  dependent 
upon  Changes  in  the  Pelvic  Obliquity. 


posture.  When  standing,  the  supporting  arch  (sacro-cotyloid)  is 
formed  by  the  sacrum,  the  acetabula,  and  the  strong  beams  of 
the  ilia,  which  extend  between  the  acetabula  and  the  auricular 
surfaces  of  the  bones ;  and,  when  sitting,  it  is  composed  of  the 


THE  OBLIQUITY  OF  THE  PELVIS  2.3 

sacrum,  the  tubera  ischii  and  the  bone  which  extends  between 
these  parts  (ischio-sacral  arch). 

The  anterior,  or  pubic,  arch  unites  the  anterior  extremities  of 
the  two  segments  (sacro-cotyloid  and  ischio-sacral)  of  the  posterior 
arch,  and  forms  a  strong  tie-beam,  which  binds  these  extremities 
in  position  and  prevents  them  from  diverging  outwards. 

Since  the  sacrum  occupies  the  centre  of  the  important  posterior 
arch,  and  is  the  bone  through  which  the  body-weight  is  trans- 
mitted to  the  ossa  innominata,  it  is  important  to  consider  in  some 
detail  its  articulation  with  these  bones.  As  already  stated,  the 
anterior  surface  of  the  sacrum  is  of  greater  extent  than  the 
posterior,  and  so  great  is  the  difference  in  transverse  width  of 
these  surfaces  that  on  section  the  sacrum  appears  to  be  sus- 
pended between  the  two  ilia  by  means  of  the  powerful  posterior 
sacro-iliac  ligaments,  and  to  be  prevented  by  them  from  being 
pushed  forwards  by  the  body-weight  into  the  pelvis.  It  appears, 
in   fact,  as   if  that    component   of  the   body-weight  which  acts 


Fig.    18. — Diagram  showing  the  Relation  of  the  Sacrum  to  the  Ossa 

Innominata. 

a,  Symphysis  ;  b,  sacrum. 

The  arrows  show  where  the  outward  leverage  action  of  the  sacro-iliac 
ligaments  is  exerted. 

downwards  and  forwards  in  the  plane  of  the  pelvic  brim  is, 
on  account  of  the  inverted  wedge-shape  of  the  sacrum,  entirely 
counteracted  by  the  posterior  sacro-iliac  ligaments,  and  trans- 
mitted by  their  pull  to  the  ilia. 

Without  doubt  these  ligaments  do  exercise  an  important  func- 
tion in  this  manner,  and  are  the  chief  media  through  which  the 
weight  of  the  body,  acting  through  the  base  of  the  sacrum,  is 
transmitted  to  the  lateral  portions  of  the  arch  ;  but  their  impor- 
tance has  been  somewhat  overestimated,  for  a  considerable  portion 
of  the  weight  can  be  transmitted  directly  from  one  bone  to  the 
other.  This  can  be  proved  by  an  examination  of  transverse 
sections  made  at  different  levels  through  the  articulation,  and  by 
an  examination  of  the  fresh  surfaces  of  the  bones  after  disarticula- 
tion. By  these  means  the  following  facts  can  be  observed : — 
(1)  At  the  upper  portion  of  the  articulation  a  distinct  wedge 
shaped  projection  of  the  auricular  surface  of  the  sacrum  fits  into 


24  OBSTETRICAL  ANATOMY—MATERNAL  AND  OVULAR 

a  corresponding  depression  on  the  auricular  surface  of  the  ilium. 
This  projection  varies  much  in  size,  and  causes  a  reversal  of  the 
general  wedge-shaped  character  of  the  sacrum — i.e.,  at  its  level  the 
sacrum  is  wider  posteriorly  than  in  front.  (2)  At  the  anterior  part 
of  the  joint  there  is  a  slight,  but  distinct,  inward  lipping  of  the 
ilium,  which  causes  the  ilium  to  overlap  to  some  extent  the  front 
of  the  sacral  articular  surface.  The  presence  of  this  lip  permits  of 
the  direct  transmission  of  weight  from  the  sacrum  to  the  femur 
through  the  strong  connecting-bar  of  the  ilium.  The  lip  does 
not  exist  in  the  foetal  pelvis,  and  is  evidently  produced  as  the 
result  of  pressure  and  counter-pressure  when  the  bones  are  still 
plastic.  (3)  Some  locking  of  the  bones  is  caused  by  the  general 
irregularity  of  the  opposed  surfaces. 

When  a  coronal  section  of  the  sacrum  is  made  in  the  direction 
of  its  long  axis,  it  is  found  that  in  this  direction  it  forms  a  true 
wedge  between  the  iliac  bones,  the  apex  of  which  is  below  and 
the  base  above.*  This  adaptation  of  the  bones,  aided  by  the 
suspensory  action  of  the  posterior  sacro-iliac  ligaments,  prevents 
the  sacrum  being  driven  downwards  and  backwards  by  that 
component  of  the  body-weight  which  acts  in  the  direction  of  its 
axis  (see  below). 

The  centre  of  gravity  of  the  body  is  situated  just  above  the 
sacro-lumbar  articulation,  nearer  to  the  anterior  than  to  the 
posterior  margin  of  the  body  of  the  first  sacral  vertebra,!  and 
through  this  point  the  resulting  force  of  the  body-weight  acts 
vertically  downwards  upon  the  base  of  the  sacrum.  This  force 
may  be  resolved  into  two  components,  one  acting  downwards  and 
forwards  in  the  plane  of  the  pelvic  brim,  and  the  other  downwards 
and  backwards  along  the  axis  of  the  upper  portion  of  the  sacrum. 
(v.  Figs.  16,  17).  The  first  component  tends  to  drive  the  sacrum 
forwards,  and,  as  we  have  seen,  is  transmitted  to  the  ilium  by  the 
posterior  sacro-iliac  ligaments  and  by  the  interlocking  of  the  bones. 
The  second  component  tends  to  drive  the  sacrum  downwards  and 
backwards,  and  is  transmitted  to  the  ilia  by  the  wedge-shaped 
character  of  the  articulation  and  by  the  upper  portion  of  the  same 
ligaments.  A  constant  strain  is  thus  exerted  upon  the  sacro-iliac 
ligaments,  and  these,  pulling  upon  that  part  of  the  innominate  bones 
that  lies  posterior  to  the  articulation,  as  upon  the  short  arm  of  a 
lever,  tend  to  cause  the  anterior  extremities  of  the  posterior  pelvic 
arch  to  diverge.  This  tendency  to  outward  deviation  is  resisted 
by  the  anterior  pelvic  arch,  a  fact  which  is  well  illustrated  by  ob- 
serving the  way  in  which  the  ossa  innominata  start  apart  when 
the  ligaments  of  the  pubic  symphysis  are  cut  in  the  operation  of 
symphysiotomy. 

-■'  This  wedge-shape  is  less  marked  than  might  at  first  sight  appear.  The 
articular  surface  of  the  sacrum  is  only  present  on  the  upper  three  sacral  ver- 
tebras, and  is  often  almost  vertical  in  direction.  It  is  usually  more  oblique 
from  above  downwards  and  inwards  in  the  female  than  in  the  male. 

f  It  is  situated  slightly  to  the  right  of  the  mesial  plane  (Struthers,  John, 
Edin.  Med.  Joiirn.,  1863). 


THE  MALE  AND  FEMALE  PELVIS 


25 


It  was  formerly  supposed  that  no  movement  took  place  at 
the  sacro-iliac  joint ;  but,  since  the  researches  of  Matthews 
Duncan,"  it  has  generally  been  admitted  that  there  is  a  constant 
slight  motion  of  the  sacrum  on  a  transverse  axis,  passing  through 
the  second  segment  of  the  bones,  brought  about  by  the  force  of 
the  body-weight,  and  causing  the  position  of  the  sacrum  to  alter 
with  variations  of  the  position  of  the  body.  Thus,  when  the  body 
is  bent  forwards,  the  base  of  the  sacrum  is  projected  downwards 
and  forwards  to  a  slight  extent,  the  antero-posterior  diameter  of 
the  brim  is  diminished,  and  the  obliquity  of  the  pelvis  is  some- 
what lessened.  At  the  same  time,  the  apex  of  the  sacrum  moves 
upwards  and  backwards,  but  performs  a  greater  excursion  than 
the  base,  owing  to  the  axis  of  motion  being  situated  nearer  to 
the  latter.  A  reverse  series  of  movements  take  place  when  the 
body  again  assumes  a  vertical  position.      To  quote    Matthews 


Fig.   19. — Diagram  showing  Nutation  of  Sacrum  during  Parturition. 

The  red  outline  represents  the  position  of  the  sacrum  when  the  head  is 

approaching  the  pelvic  outlet.     (After  Matthews  Duncan.) 


Duncan,!  '  The  movements  which  occur  may  be  described  as 
consisting  in  the  elevation  and  depression  of  the  symphysis  pubis, 
the  ilia  moving  upon  the  sacrum  ;  or  if  the  sacrum  be  regarded 
as  the  moving  bone,  it  describes  a  nutatory  motion  upon  an 
imaginary  transverse  line,  passing  through  the  second  bone.' 

The  sacro-sciatic  ligaments  exert  a  powerful  influence  in  limit- 
ing the  above-described  movements  by  binding  the  lower  part  of 
the  sacrum  in  position.  The  changes,  which  they  and  the  other 
ligamentous  structures  of  the  pelvis  undergo  during  pregnancy 
permit,  however,  a  greatly  increased  range  of  motion. 

Differences  between  Male  and  Female  Pelvis. — If  typical 

*  'Contributions  to  Mechanism  of  Natural  and   Morbid  Parturition,'  by 
J.  Mathews  Duncan,  1875,  pp.  152,  153. 
-j-  Loc.  cit. 


26 


OBSTETRICAL  AN  ATOMY -MATERNAL  AND  OVULAR 


specimens  of  male  and  female  pelves  are  compared,  several  im- 
portant points  of  distinction  will  be  noticed,  some  of  which  are 
due  to  the  difference  in  muscular  development  and  habits  of 
the  sexes,  while  others  are  obviously  sexual  in  character  and 
depend  upon  the  peculiar  function  which  the  female  pelvis  has  to 
perform. 

The  female  pelvis  is  altogether  built  on  a  more  slender  scale 
than  the  male,  the  individual  bones  are  lighter,  and  the  impres- 
sions for  the  attachment  of  muscles  are  less  marked.  The  depth 
of  the  cavity  is  less,  while  its  breadth  and  capacity  are  much 
greater.  The  inlet  is  more  regular,  and,  owing  to  the  compara- 
tively slight  forward  projection  of  the  sacral  promontory,  it  is 


Fig.  20. — Male  Pelvis. 
(Slightly  less  than  one-third  natural  size.) 


more  oval  than  heart-shaped  in  contour,  and  its  antero-posterior 
diameter  is  increased.  Looked  at  as  a  whole,  the  pelvis  is  seen  to 
present  fewer  angles  in  the  female,  to  have  a  more  hollowed-out 
appearance,  and  to  present  much  less  lateral  compression.  The 
circumference  of  the  brim  measures  in  the  female  about  17  inches, 
and  in  the  male  only  15^  inches. 

The  female  sacrum  is  broader  and  slightly  shorter  than  the 
male,  and,  instead  of  presenting  a  uniform  curve  throughout  its 
entire  length,  is  almost  flat  in  its  upper  two-thirds,  while  its  lower 
third  is  distinctly  bent  forwards  and  downwards.  Its  transverse 
curvature  is  also  less,  and,  as  a  result  of  the  diminished  forward 
projection  of  its  promontory,  the  pelvis  as  a  whole  is  less  oblique. 


THE  MALE  AND  FEMALE  PELVIS 


17 


A  most  striking  difference,  and  one  which  enables  as  a  rule 
the  male  and  female  pelves  to  be  at  once  distinguished,  is  the 
width  of  the  sub-pubic  angle  and  the  depth  of  the  symphysis  pubis. 
In  the  female,  the  rami  of  the  pubis  meet  at  an  angle  of  from 
go°  to  iooc,  and,  owing  to  the  presence  of  the  sub-pubic  ligament, 
the  angle  is  rounded  off  into  a  gentle  curve.  In  the  male,  the 
angle  is  always  acute,  and  varies  from  700  to  750.  The  depth  of 
the  symphysis  is  much  less  in  the  female  than  in  the  male,  and 
the  breadth  of  the  pubic  bone  is  greater.  This  diminished  depth, 
together  with  the  greater  divergence  of  the  pubic  rami,  accounts 
for  the  shallowness  of  the  anterior  part  of  the  female  pelvis,  while 
the  great  breadth  of  the  body  of  the  pubis  gives  the  obturator 
foramen  a  triangular  form.  The  horizontal  ramus  of  the  pubis 
is  longer,  more  slender,  and  passes  more  directly  outwards  ;  the 
tubera  ischii  are  more  widely  separated  and  the  ischial  spines 
are  less  prominent ;  furthermore,  the  sciatic  notches  are  much 
more  extensive,  being  both  wider  and  shallower  in  the  female. 
Thomson"  has  shown  that  the  distance  from  the  posterior  inferior 
iliac  spine  to  the  anterior  margin  of  the  great  sciatic  notch  is 
greater  in  the  female  than  in  the  male,  and  that  therefore  the 
characteristic  form  of  the  female  notch  is  due  to  the  greater 
length  of  the  posterior  portion  of  the  ilium.  This  increased 
length  of  the  ilium  he  regards  as  a  marked  sexual  characteristic, 
and  states  that  it  is  present  even  in  the  fcetal  pelvis. 

Turning  to  the  false  pelvis,  it  is  seen  that  the  iliac  crests  are 
less  curved  in  the  female  and  that  the  iliac  fossae  are  more  broad 
and  expanded,  thus  giving  rise  to  the  characteristic  prominence 
of  the  hips,  a  prominence  which  is  accentuated  by  the  fact  that 
the  large  transverse  diameter  causes  the  acetabula  to  be  set 
widely  apart.  The  femora,  in  consequence  of  being  so  widely 
separated  at  their  superior  articulation,  incline  inwards  to  the 
knee  to- a  greater  extent  than  in  the  male,  and  so  give  rise  to 
the  characteristic  side-to-side  gait  of  women.  On  the  whole,  the 
female  pelvis  forms  a  shorter  and  wider  canal  than  the  male,  and 
is  thus  suited  to  contain  the  reproductive  organs,  and  to  give 
passage  to  the  foetus. 

The  following  comparative  measurements  are  taken  from 
Quainf  (slightly  modified)  : — 


Diameter. 

Male. 

Female. 

Brim. 

Cavity. 

Outlet. 

Brim. 

Cavity. 

Outlet. 

Antero-posterior 
Transverse 
Oblique  - 

4  in. 

5  in. 
4f  in. 

4iin- 
4|m. 
4*  in. 

3£in. 

32  in- 
4  in. 

4jin- 
5iin. 
5  m. 

5  in. 
5  in. 
5iin. 

3f  in. 

4f  in. 
4f  in. 

*   '  Sexual  Differences  of  the  Foetal  Pelvis  '   (Arthur  Thomson,  Journal  of 
Physiology,  vol.  xxxiii. ,  p.  359). 

t  Quain's  'Anatomy,'  tenth  edition,  vol.  ii.,  part  i.,  p.  118 


28  OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 

Development  of  the  Pelvis. — The  form  and  relative  pro- 
portions of  the  pelvis  in  the  infant  differ  widely  from  what  is  found 
in  the  adult,  but  even  at  birth  the  more  prominent  sexual  charac- 
teristics are  present.  At  birth,  the  inclination  of  the  pelvic  brim 
is,  when  the  limbs  are  extended,  greater  than  in  the  adult ;  the 
sacral  promontory  is  placed  at  a  higher  level,  but  does  not  project 
so  much  into  the  cavity  ;  the  iliac  fossae  are  rather  flat,  and  directed 
more  forwards  than  inwards,  and  the  iliac  crests  are  only  slightly 
curved.  The  sacrum  is  less  curved  vertically,  and  was  formerly 
believed  to  be  disproportionately  narrow,  on  account  of  the  small 
degree  of  development  of  its  alas.  Thomson  has,  however, 
shown  that  it  is  really  wider  in  proportion  than  in  the  adult, 
though  its  maximum  width  lies  above  the  level  of  the  inlet  of  the 
pelvis.  The  pubic  angle  is  acute,  and  the  width  of  the  pubic  bones 
is  proportionately  less.  The  lateral  walls  are  almost  parallel,  but 
tend  to  slope  inwards  inferior ly  and  bring  the  tubera  ischii  and 
ischial  spines  nearer  to  one  another.  Even  at  birth,  however,  the 
characteristic  preponderance  of  the  transverse  over  the  conjugate 
diameter  is  present.  The  height  of  the  foetal  pelvis  in  proportion 
to  its  width  is  much  greater  than  in  the  adult. 

During  the  period  of  growth,  the  form  of  the  pelvis  is  modified 
by  two  main  factors,  the  first  of  which  consists  in  the  dispropor- 
tionate growth  of  some  parts  of  the  pelvis  as  compared  with 
others,  and  the  second  the  mechanical  effect  of  the  body-weight. 
The  action  of  the  muscles,  which  are  attached  to  the  pelvis  also 
takes  some  part  in  producing  alterations  in  form.  All  of  these 
factors  are  enabled  to  bring  about  considerable  alterations  in 
shape  owing  to  the  ductile  character  of  the  bones,  and  to  the 
manner  in  which  each  of  them  is  developed  in  several  parts. 
In  the  sacrum,  the  atae  grow  more  rapidly  than  the  central  part, 
and  thus  enable  the  transverse  diameter  to  maintain  its  relation 
to  the  conjugate,  although  this  latter  is  becoming  rapidly  increased 
in  length  by  the  antero-posterior  growth  of  the  ilium.  The 
pubic  bones  during  growth  also  increase  rapidly  in  a  transverse 
direction. 

The  manner  in  which  the  body-weight  is  transmitted  to  the 
lower  limbs  has  been  already  described,  and  the  few  remarks 
which  will  now  be  added  will  enable  the  reader  to  appreciate  how 
the  weight  operates  in  producing  some  of  the  varieties  of  deformed 
pelvis  that  occur  when  the  position  of  centre  of  gravity  of  the  body 
is  altered  by  spinal  curvature,  or  when  the  bones  are  rendered 
abnormally  soft  by  rachitic  changes. 

During  growth,  the  action  of  the  body-weight  upon  the  sacrum 
is  twofold,  producing  changes  in  its  shape  and  position.  That 
component  of  it,  which  acts  along  the  plane  of  the  pelvic  brim, 
forces  the  sacrum  to  sink  downwards  and  forwards  between  the 
ilia,  and  therefore  causes  the  promontory  to  gradually  assume  its 
normal  adult  level.  In  producing  this  effect,  the  component  of  the 
body-weight  which  acts  along  the  long  axis  of  the  sacrum  also 


DEVELOPMENT  OF  THE  PELVIS  29 

exerts  some  influence,  and,  at  the  same  time,  the  pull  of  the 
posterior  sacro-iliac  ligaments  causes  the  ilia  to  become  more 
approximated  posteriorly  behind  the  sacrum.  Should  the  sacrum 
be  abnormally  yielding,  the  forward  strain  exerted  upon  it  will 
cause  its  transverse  concavity  to  disappear  and  to  be  replaced  by 
a  convexity,  owing  to  the  central  part  moving  forwards  anterior 
to  the  lateral  portions,  which  remain  fixed  by  their  ligamentous 
attachments. 

The  body- weight,  as  a  whole,  acting  downwards  through  a  point 
situated  nearer  to  the  anterior  than  the  posterior  margin  of  the  base 
of  the  sacrum,  tends  to  make  that  bone  rotate  on  its  transverse 
axis.  The  lower  part  of  the  sacrum  is,  however,  held  fixed  in 
position  by  the  tension  of  the  sacro-sciatic  ligaments,  and,  in  con- 
sequence, the  bone,  unable  to  rotate,  becomes  curved  vertically  by 
the  pressure.  In  this  manner,  the  inlet  and  the  outlet  of  the  true 
pelvis  become  constricted  and  the  conjugate  diameter  within  the 
cavity  is  increased. 

When  considering  the  pelvic  arches,  it  was  stated  that  the 
anterior  extremities  of  the  posterior  arch  tended  to  start  asunder 
as  a  result  of  the  pull  of  the  sacro-iliac  ligaments,  and  that  this 
tendency  was  counteracted  by  the  strong  tie-beam  formed  by  the 
pubic  arch  in  front.  During  growth,  when  the  bones  are  soft,  this 
action  of  the  body-weight  tends  to  make  the  innominate  bones 
become  more  curved,  and  as  the  maximum  outwardly  directed 
force  is  situated  in  the  neighbourhood  of  the  acetabula,  we  would 
expect  to  find  the  concavity  greatest  in  this  position,  where,  more- 
over, the  bones  are  most  liable  to  yield  in  consequence  of  the 
cartilaginous  union  of  their  various  parts.  Their  tendency  to 
curve  in  this  position  is,  however,  resisted  by  the  inward  pressure 
of  the  heads  of  the  femora,*  and,  in  consequence,  the  greatest 
concavity  of  the  bone  brought  about  by  the  body  weight  becomes 
situated  more  posteriorly  where  the  ilium  is  thinnest,  just  in  front 
of  its  articular  surface.  The  development  of  a  pronounced  cavity 
here  has  a  further  marked  effect  in  increasing  the  extent  of  the 
transverse  diameter  of  the  brim. 

*  This  inward  pressure  is  entirely  the  result  of  muscular  action. 


CHAPTER  II 

ANATOMY  OF  GENITAL  ORGANS,  PELVIC  FLOOR,  AND 
MAMMARY  GLANDS 

External  Genitals  :  Labia  Majora  ;  Labia  Minora  ;  Clitoris  ;  Hymen  ;  Glands 
of  Bartholin;  The  Vagina — Internal  Genitals:  The  Uterus,  Relations, 
Position,  Structure ;  The  Fallopian  Tubes  ;  The  Ovaries,  Structure ; 
Graafian  Follicle— The  Ureter ;  The  Bladder  ;  The  Rectum— The  Pelvic 
Floor  ;  Perineum  ;  Pelvic  Diaphragm  ;  Muscles  of  Pelvis — The  Mam- 
mary Glands. 

The  reproductive  organs  of  the  female  may  be  described  under 
two  headings:  — 

I.  The  external  genitals,  including  the  vagina. 

II.  The  internal  genitals. 


THE  EXTERNAL  GENITALS 

The  external  genitals  comprise  the  mons  veneris,  the  labia 
majora,  the  labia  minora  or  nymphas,  the  clitoris,  and  the  hymen, 
and  to  these  structures  the  general  term  of  vulva  or  pudendum  is 
applied.  They  surround  the  orifice  of  the  vagina,  and  are  placed 
for  the  most  part  within  the  anterior  or  urogenital  triangle  of  the 
perinaeum.  With  them  may  be  considered  the  vagina,  which  is 
a  muscular  canal  extending  from  the  lower  portion  of  the  uterus 
to  the  vulva,  and  bringing  the  cavity  of  that  organ  into  communica- 
tion with  the  exterior.  It  is  principally  of  interest  to  the  obstet- 
rician as  forming  a  canal  through  the  pelvic  floor,  which  is  capable 
of  enormous  expansion,  and  which  permits  the  passage  of  the 
child  during  parturition.  Its  lower  portion  lies  below  the  plane 
of  the  pelvic  outlet,  and,  together  with  the  surrounding  structures, 
forms  what  is  called  by  the  French  'the  dilatable  pelvis.' 

The  Mons  Veneris. — The  mons  veneris  forms  the  most  anterior 
portion  of  the  vulva,  and  is  situated  over  the  symphysis  pubis.  It 
constitutes  an  eminence  formed  by  a  mass  of  areolar  and  fatty 
tissue,  and  is  covered  by  integument,  which  is  continuous  above 
with  that  of  the  hypogastrium.  It  is,  however,  marked  off  from 
the  hypogastric  region  by  a  faint  transverse  depression.  After 
puberty,  it  becomes  covered  with  an  abundant  supply  of  crisp  hairs, 

30 


THE  LABIA  MAJOR  A 


.5' 


and  has  opening  upon  it  the  ducts  of  numerous  sudoriparous  and 
sebaceous  glands. 

The  Labia  Majora. — The  labia  majora  are  two  rounded  folds  of 
integument  supported  by  fatty  and  fibrous  tissue,  together  with 
some  involuntary  muscular  fibres.  They  form  the  lateral  boun- 
daries of  the  vulva  and  are  homologous  to  the  scrotum  in  the 
male.     Anteriorly,  they  unite  to  form   the  lower  portion  of  the 


Fig.  21. — The  Vulva. 

a,  Labia  majora  ;  b,  labia  minora  ;  c,  meatus  urinarius ;  d,  glans  clitoridis 
c,  clitoris  ;  /,  mons  veneris.     (Sharpey.) 


mons  veneris,  and  from  thence  proceed  in  a  slightly  curved  direc- 
tion downwards  and  backwards  to  a  point  about  an  inch  in  front 
of  the  anus,  where  they  become  united  by  a  transverse  fold  of  skin 
known  as  the  posterior  commissure.  Occasionally,  they  do  not 
unite  posteriorly,  but  pass  backwards  to  the  side  of  the  anus,  where 
they  gradually  fade  away.  The  outer  surface  of  each  labium  is 
convex  and  is  covered  with  skin  provided  with  numerous  hairs 


32         OBSTETRICAL  ANATOMY—MATERNAL  AND  OVULAR 

and  sebaceous  glands.  The  inner  surfaces  in  nulliparae  are  in 
contact  with  one  another,  and  are  covered  with  soft,  smooth 
integument  of  a  pinkish  colour,  which  is  usually  moistened  by 
the  secretion  of  large  sebaceous  glands.  Within  the  substance 
of  each  fold,  are  some  non-striated  muscular  fibres,  homologous 
to  the  dartos  muscle  in  the  male,  together  with  fat,  bloodvessels, 
and  nerves.  The  close  apposition  of  these  folds  in  the  virgin 
usually  conceals  the  remaining  structures  of  the  vulva,  a  median 
cleft  only  being  visible  (urogenital  cleft),  but  in  multipara?  and  in 
the  aged,  owing  to  the  wasting  of  the  adipose  tissue  which  sup- 
ports them,  they  frequently  become  separated  and  expose  to  view 
the  labia  minora.  Hypertrophy  of  the  last  named  may  also  cause 
separation  of  the  labia  majora.  Under  these  circumstances,  the 
inner  aspects  of  the  labia  lose  their  mucous  membrane-like  appear- 
ance, and  the  integument  covering  them  becomes  thickened  and 
hardened. 

The  Labia  Minora. — The  labia  minora,  or  nymphae,  are  two  pen- 
dulous folds  of  skin  placed  on  the  inner  aspect  of  the  labia  majora. 
Posteriorly,  they  usually  end  by  blending  with  the  inner  surface  of 
the  corresponding  labium  majus,  but  in  some  cases  they  become  con- 
tinuous on  each  side  with  the  fourchette,*  a  slightly  crescentic  fold 
of  skin,  which  lies  immediately  within  the  posterior  commissure. 
Anteriorly,  they  are  somewhat  elongated,  and  converge  towards 
the  clitoris,  at  the  side  of  which  each  divides  into  two  parts.  The 
posterior  or  inferior  part  blends  on  each  side  with  the  under 
surface  of  the  glans  clitoridis,  forming  the  so-called  frenulum 
clitoridis,  while  the  anterior  or  superior  part  passes  in  front  of 
the  glans,  and  becoming  continuous  with  the  corresponding  fold 
of  the  opposite  side,  forms  a  sort  of  hood  over  the  glans  called 
the  praeputium  clitoridis.  The  outer  surface  of  each  nympha  is 
in  contact  with  the  labium  majus,  and  the  inner  surfaces  are 
closely  applied  to  one  another.  In  young  subjects  these  folds 
are  of  a  delicate  pink  colour,  but  in  the  aged  they  become  pig- 
mented and  roughened  owing  to  exposure  to  the  air  and  contact 
with  the  clothes. 

The  Clitoris  and  Vestibule. — With  the  clitoris  may  be  described 
the  vestibule,  and  the  principal  erectile  structures  which  com- 
prise, besides  the  clitoris  itself,  the  two  crura  clitoridis  and  the 
bulb  of  the  vestibule. 

The  clitoris,  the  homologue  of  the  penis,  forms  a  small  projec- 
tion placed  just  behind  the  anterior  commissure.  Above  and 
below,  it  is  covered  by  a  fold  of  skin  derived  from  the  nympha?. 
In  structure,  it  closely  resembles,  though  on  a  much  smaller  scale, 
the  male  organ,  with  the  exception  that  it  is  not  perforated  by  the 
urethra.  It  is  composed  of  two  corpora  cavernosa,  which  unite  to 
form  the  body  of  the  organ,  and  which  diverge  posteriorly  to 
form  the  crura  clitoridis.  These  latter  are  attached  on  each  side 
to  the  rami  of  the  ischium  and  pubis,  and  are  covered  by  the  fibres 
*  Waldeyer,  '  Das  Becken,'  p.  552. 


THE  CLITORIS  AND  VESTIBULE  33 

of  the  erector  clitoridis  muscle.  The  extremity  of  the  organ  is 
formed  by  a  small  rounded  glans,  which  caps  the  anterior  extremity 
of  the  corpora  cavernosa.  The  glans  is  formed  of  erectile  tissue 
and  is  continuous  along  the  under  surface  of  the  clitoris  with 
a  small  venous  plexus,  the  pars  intermedia  of  Kobelt,  which  joins 
the  bulb  posteriorly.  The  bulb  of  the  vestibule  itself  constitutes 
two  oval  masses  of  erectile  tissue,  which  lie  one  on  each  side 
of  the  orifice  of  the  vagina  superficial  to  the  triangular  ligament, 
and  which  become  structurally  continuous  with  one  other,  in  front 
of  the  urethral  orifice,  through  the  pars  intermedia.  The  inner 
aspect  of  each  mass  is  covered  by  the  mucous  membrane  of  the 
lower  portion  of  the  vagina,  and  over  its  outer  aspect  are  spread 
the  fibres  of  the  bulbo-cavernosus  (superficial  sphincter  vaginae) 
muscle.  In  addition  to  these  specialised  portions  of  erectile  tissue, 
the  whole  of  the  labium  majus  is  abundantly  supplied  with  blood- 
vessels, and  is  probably  capable  of  passing  into  a  condition  of 
semi-erection.  Erectile  tissue  is  also  found  in  the  walls  of  the 
vagina. 

The  whole  of  the  clitoris  is  abundantly  supplied  with  nerves, 
and  in  the  glans  many  of  them  terminate  in  special  end  organs, 
known  as  genital  corpuscles. 

When  the  labia  majora  are  forcibly  separated  from  one  another, 
a  triangular  space  is  exposed,  bounded  in  front  by  the  clitoris, 
behind  by  the  orifice  of  the  vagina,  and  on  each  side  by  the 
nymphae.  To  this  space  the  term  vestibule  is  applied,  and  within 
it  is  seen  the  orifice  of  the  urethra  situated  about  an  inch  posterior 
to  the  clitoris  and  slightly  in  front  of  the  anterior  margin  of  the 
vaginal  orifice. 

The  urethral  orifice,  or  meatus  urinarius,  presents  a  central 
depression  surrounded  by  an  elevated  ridge -covered  with  mucous 
membrane.  This  ridge  has  a  somewhat  puckered  appearance 
owing  to  the  tonic  contraction  of  the  muscular  fibres  which  lie 
immediately  subjacent  and  which  form  a  superficial  sphincter 
muscle.  The  meatus  lies  in  the  middle  line,  and  just  in  front  of 
it  on  each  side  is  placed  the  orifice  of  a  small  tubular  gland 
which  lies  imbedded  in  the  muscular  wall  of  the  urethra.  These 
glands  were  first  described  by  Skene,*  and  are  usually  called  by 
his  name.  Possibly  they  represent  the  anterior  extremity  of 
Gartner's  ducts. 

The  female  urethra  is  about  an  inch  and  a  half  in  length,  and 
extends  from  the  neck  of  the  bladder  in  a  direction  downwards 
and  forwards  beneath  the  pubic  arch  to  the  urinary  meatus.  It 
bears  the  same  relation  to  the  pelvic  fascia  and  to  the  triangular 
ligament  as  in  the  male,  and  is  surrounded,  except  on  its  posterior 
aspect,  where  it  lies  imbedded  in  the  vaginal  wall,  by  the  fibres  of 
the  compressor  urethras  muscle.  The  mucous  membrane  lining  it 
is  continuous  with  that  of  the  bladder,  and,  except  during  micturi- 

*  Skene,  American  Journal  of  Obstetrics,  April,  1880. 


34 


OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 


tion,  is  raised  into  longitudinally  running  folds  by  the  tonic  con- 
traction of  the  muscles  which  surround  the  canal. 

The  Hymen. — The  hymen  forms  the  anatomical  and  functional 
entrance  to  the  vagina. *  It  is  a  crescentic  fold  of  integument 
and  mucous  membrane  attached  by  its  convex  margin  to  the 
posterior  and  lateral  parts  of  the  vulvo-vaginal  entrance.  Its 
concave  margin  is  free  and  directed  forwards,  forming  the  boun- 
dary of  the  introitus  vaginae.  Its  superficial  or  inferior  surface 
is  continuous  with  the  integument  of  the  vulva,  and  is  separated 
posteriorly  from  the  fourchette  by  a  small  depression,  the  fossa 


Fig.  22. — Diagram  of  Normal  Hymen  in  a  Virgin. 


navicularis.  Its  superior  or  deep  surface  is  formed  by  an  exten- 
sion forwards  of  the  mucous  membrane  of  the  posterior  vaginal 
wall,  and  some  of  the  vaginal  rugae  can  be  traced  forwards  on  to 
it.  Between  its  two  layers  are  contained  some  muscular  fibres, 
together  with  a  few  small  bloodvessels  and  nerves. 

The  vaginal  orifice,  thus  bounded  by  the  hymen,  is  usually  oval 
in  shape,  with  its  long  axis  directed  from  before  backwards,  and 
will  only  admit  the  tip  of  the  little  finger.     It  is,  however,  variable 

*  Berry  Hart,  '  Atlas  of  Female  Pelvic  Anatomy,'  p.  7. 


THE  HYMEN 


35 


in  size  and  shape,  depending  on  variations  in  form  of  the  hymen. 
Thus  the  hymen  may  be  absent,  or  it  may  form  a  complete 
septum  occluding  the  lower  portion  of  the  vagina  (hymen  imper- 
foratus). It  may  form  a  complete  ring  with  a  small  central  or 
eccentric  opening  ;  it  may  be  cribriform  or  present  two  orifices 
separated  from  one  another  by  a  central  band  ;  its  free  margin 
may  present  a  number  of  papillae,  or  very  frequently  a  series  of 
slight  indentations.  From  a  medico-legal  and  diagnostic  point 
of  view,  it  is  important  to  remember  that  such  indentations  do 


Fig.  23. — Diagram  of  Hymen  after  Coitus. 


not  extend  throughout  the  whole  depth  of  the  membrane,  being 
merely  notches  in  the  concave  margin,  and  that,  furthermore,  the 
edges  of  such  notches  are  even,  and  are  lined  by  smooth  and  con- 
tinuous mucous  membrane. 

The  hymen  is  usually  ruptured  by  the  first  coitus,  and  hence 
has  arisen  the  custom  in  many  countries  of  regarding  it  when 
intact  as  a  sign  of  virginity.  This  sign,  although  useful  in  con- 
junction with  other  evidence,  is,  however,  by  no  means  infallible, 
for   the    membrane   may    be    ruptured    by   a    sudden    muscular 

3—2 


36 


OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 


strain,  for  example,  stretching  the  limbs,*  or  by  a  vaginal 
examination  ;  and,  on  the  other  hand,  it  is  sometimes  so  elastic 
and  distensile  that,  instead  of  rupturing  during  coitus,  it  folds 
inwards  and  comes  in  contact  with  the  vaginal  wall.  It  has 
even  been  known  to  remain  unbroken  after  the  birth  of  a 
seven  months'  child.  Ruptures  from  coitus  or  from  violence 
usually  extend  through  the  whole  depth  of  the  membrane  and 
present  ragged  and  uneven  margins. 

In  women  who  have  borne  children  the  hymen  is,  as  a  rule, 


Fig.  24.— Diagram  of  Hymen  after  Delivery,  showing  Caruncul^: 
Myrtiformes. 


absent,  its  place  being  taken  by  a  series  of  rounded  and  irregular 
tubercles  called  the  carunculae  myrtiformes.  These  fleshy  eleva- 
tions are  quite  distinct  from  one  another,  and  are  regarded  by 
Schroeder  as  isolated  portions  of  the  hymen,  the  intervening  parts 
of  which  have  necrosed  owing  to  the  pressure  to  which  they  were 
subjected  during  labour.  According  to  the  same  authority,  they 
are  never  found  except  after  parturition.  Others,  however,  main- 
tain that  they  have  no  connection  with  the  hymen,  but  are  inde- 

*  Playfair,  '  The  Science  and  Practice  of  Midwifery,'  vol.  L,  p.  27. 


THE   VAGINA  37 

pendent  papillary  outgrowths.  Their  anatomical  structure  and 
position,  however,  support  the  former  view. 

Glands  of  Bartholin. — On  each  side  of  the  orifice  of  the  vagina, 
in  the  groove  between  the  attached  border  of  the  hymen  and  the 
posterior  extremity  of  the  labium  minus,  is  situated  the  orifice  of 
a  small  duct.  These  ducts  are  about  half  an  inch  in  length, 
and  are  derived  from  glands  known,  after  their  discoverer,  as 
Bartholin's  glands.  The  latter  are  homologous  to  Cowper's  glands 
in  the  male,  and  lie  in  the  same  anatomical  plane.  They  are 
larger,  however,  each  gland  attaining  the  size  of  a  small  hazel- 
nut. Both  glands  are  of  a  reddish-yellow  colour,  and  secrete  a 
yellowish  fluid,  which  helps  to  lubricate  the  vulva  during  coitus 
and  parturition. 

The  Vagina. — The  vagina  is  a  musculo-aponeurotic  canal,  which 
is  closed  above  by  its  attachment  to  the  cervix  uteri,  and  which 
passes  from  thence  downwards  and  forwards,  to  open  on  the  vulva 
by  means  of  the  ovificium  vagina.  It  is  much  wider  above 
than  below,  and  thus,  when  distended,  presents  a  somewhat  cone- 
shaped  appearance.  Its  long  axis  normally  lies  parallel  to  the 
plane  of  the  pelvic  brim,  and  forms  an  angle  of  about  6o°  with 
the  horizon  ;  but  this  direction  is  liable  to  some  variation  conse- 
quent on  the  distension  of  the  neighbouring  viscera.  Thus,  as 
the  rectum  becomes  filled,  it  pushes  the  upper  part  of  the  vagina 
forwards,  and  so  makes  its  axis  more  vertical ;  while,  on  the 
other  hand,  distension  of  the  bladder  makes  the  axis  more 
horizontal.  The  lower  portion  of  the  canal  passes  almost  directly 
forwards  over  the  hymen  to  its  opening  below  the  vestibule. 
The  vagina  is  normally  closed  by  the  apposition  of  its  anterior 
and  posterior  walls,  and  on  section  presents  the  appearance  of 
a  transverse  slit.  On  each  side,  however,  the  slit  opens  out 
slightly,  so  as  to  form  an  appearance  resembling  the  letter  H. 
Owing  to  the  fact  that  the  vagina  is  attached  to  the  uterus  at 
a  higher  level  posteriorly  than  it  is  in  front,  the  posterior  wall 
is  longer  than  the  anterior,  and  attains  a  length  of  from  3  to 
3-J  inches,  the  anterior  wall  being  only  about  i\  inches  long.  In 
giving  these  measurements,  however,  it  must  be  remembered 
that  the  vaginal  walls  are  capable  of  considerable  distension  in  a 
longitudinal  as  well  as  in  a  transverse  direction,  and  thus,  when 
passing  a  speculum,  this  length  may  seem  to  be  nearly  doubled. 
It  has  already  been  pointed  out  that  the  vagina  is  much  more 
capacious  above  than  below,  and  in  consequence  each  wall  is 
triangular  in  shape,  with  its  apex  situated  at  the  orifice  and  its 
base  directed  upwards. 

The  posterior  wall  is  covered  in  its  upper  part  by  peritoneum, 
which  is  reflected  on  to  it  from  the  rectum,  and  which  forms  the 
bottom  of  Douglas's  pouch.  Below  this,  it  lies  in  relation  to  the 
anterior  rectal  wall,  from  which,  however,  it  is  separated  b)r  a 
loose  double  layer  of  connective  tissue.  The  rectal  and  vaginal 
walls  remain  quite  distinct,  although  the  name  of  recto-vaginal 


38 


OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 


septum  is  often  applied  to  the  lower  portion  of  the  combined 
walls.  At  its  orifice,  the  vagina  is  separated  from  the  anal  canal 
by  the  perinseal  body.  This  body  is  often  stated  to  be  peculiar 
to  the  female,  but  it  must  be  regarded  as  being  homologous  to 
the  mass  of  connective  and  muscular  tissue  which  in  the  male 
intervenes  between  the  bulb  of  the  penis  and  the  terminal  stage 
of  the  rectum,  and  which  contains  the  central  point  of  the 
perinseum.  In  the  female  the  perinseal  body  is  wedge-shaped  in 
form,  its  base  being  constituted  by  that  portion  of  the  surface 


Fig.  25. — Sagittal  Section  through  Pelvis,  showing  Vaginal  Rug^e. 

The  vaginal  walls  are  separated  artificially,     a,  Symphysis  ;  b,  urethra; 
c,  vagina;  d,  fossa  navicularis ;  e,  hymen.     (Hart.) 


which  intervenes  between  the  rectal  and  vaginal  orifice.  Its 
apex  is  directed  upwards,  and  blends  with  the  so-called  recto- 
vaginal septum.  It  is  composed  of  dense  connective  tissue,  inter- 
mingled with  which  are  some  of  the  fibres  of  the  superficial 
perinseal  muscles,  including  the  sphincter  externus  of  the  anus 
and  some  fibres  of  the  levator  ani,  which  descend  into  it  from 
above. 

The  anterior  vaginal  wall  is  in  relation  above  to  the  bladder, 


THE    VAGINA  '    39 

and  below  has  the  urethra  embedded  within  it.  The  lateral  aspect 
is  supported  on  both  sides  by  the  levator  ani  muscle,  and  comes 
into  relation  with  the  ureter  just  at  the  point  where  it  joins  the 
uterus. 

That  portion  of  the  vagina  which  encircles  the  cervix  uteri  is 
called  the  fornix,  and  is  divided  into  an  anterior,  posterior,  and 
two  lateral  fornices.  The  posterior  fornix,  or  recess,  is  much 
deeper  than  the  anterior,  and  is  bounded  behind  by  that  portion 
of  the  posterior  vaginal  wall  which  is  covered  by  peritoneum. 
The  uterine  artery  comes  into  relation  to  each  lateral  fornix,  and, 
especially  when  enlarged  during  pregnancy,  can  be  felt  pulsating 
in  that  position. 

The  vaginal  wall  is  composed  from  within  outwards  of  a 
mucous,  muscular,  and  connective-tissue  coat.  The  mucous 
membrane  is  covered  by  a  layer  of  compound  scaly  epithelium, 
into  which  numerous  papillae  project,  and  which  extends  on  to 
the  lower  portion  of  the  cervix  uteri.  It  does  not  contain  any 
glands.  In  nullipara?,  both  the  anterior  and  posterior  walls 
present  numerous  transverse  folds  in  the  mucous  membrane, 
which  are  best  marked  at  the  lower  end  of  the  canal.  These 
folds  pass  out  on  each  side  from  one  or  more  mesially  placed 
longitudinal  folds,  and  are  obviously  adapted  to  permit  of  dilata- 
tion without  injury  to  the  mucous  membrane.  They  are  seldom 
present  after  parturition.  The  muscular  coat  consists  of  an  outer 
longitudinal  and  an  inner  circular  layer  of  smooth  muscle  fibres. 
At  the  lower  end  of  the  canal,  it  is  reinforced  by  fibres  of  the 
compressor  urethrse  and  bulbo-cavernosus  muscles.  The  longi- 
tudinal layer  of  fibres  is  best  developed  at  the  upper  part  of  the 
vagina,  and  is  continuous  above  with  the  longitudinal  fibres  of 
the  uterus.  Lying  between  this  muscular  and  mucous  coat  is 
a  thin  layer  of  erectile  tissue,  continuous  with  the  bulb  of  the 
vestibule.  External  to  the  muscular  coat,  is  found  a  rather 
indefinite  layer  of  connective  tissue,  derived  from  the  pelvic 
fascia,  and  in  which  is  embedded  a  large  plexus  of  veins.  The 
veins  are  principally  massed  at  the  side  of  the  vagina,  but  also 
extend  on  to  the  anterior  and  posterior  walls.  They  become 
enormously  dilated  in  the  later  months  of  pregnancy,  and  it  is 
from  them  that  the  serous  exudate  is  derived  that  infiltrates  and 
softens  the  tissues  prior  to  parturition.  Within  the  mucous  coat, 
an  abundant  lymphatic  plexus  is  contained,  which  is  drained, 
according  to  Waldeyer,*  in  three  directions.  The  lower  vessels 
pass,  with  those  of  the  vulva,  to  the  inguinal  glands  ;  the  middle 
pass  to  the  glands  of  the  hypogastrium ;  and  the  upper  ones, 
together  with  those  of  the  uterus,  pass  outwards  in  the  broad 
ligament  to  the  external  iliac  glands. 

*  Waldeyer,  '  Das  Becken,'  p.  538. 


4o  OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 


THE  INTERNAL  GENITALS 

The  internal  genitals  form  the  true  organs  of  conception,  and 
comprise  the  Uterus,  the  Fallopian  Tubes,  and  the  Ovaries. 
The  following  description,  except  when  otherwise  stated,  is 
intended  to  apply  to  these  viscera  as  found  in  the  virgin. 

The  Uterus. — The  uterus  is  a  hollow  viscus,  with  stout  .mus- 
cular walls  placed  within  the  pelvis,  between  the  bladder  and 
rectum,  and  connected  to  both  of  these  structures,  as  well  as  to 
the  lateral  boundaries  of  the  pelvis,  by  folds  of  peritoneum.  The 
fully-developed  nulliparous  uterus  is  pear-shaped  in  form,  with 
the  wide  end  directed  upwards,  and  the  narrow  end  projecting 
downwards  and  backwards  into  the  vagina.     It  is  flattened  from 


Fig.  26.- — View  of  the  Posterior  Surface  of  the  Uterus,  Fallopian 
Tubes,  Ovaries,  and  Broad  Ligaments. 

The  infundibulo-pelvic  ligament  is  shown  on  the  left.     (Dickinson.) 

before  backwards,  and  is  divided  by  a  slight  constriction  called 
the  isthmus  into  an  upper  portion  or  body,  and  a  lower  portion 
or  cervix,  which  are  almost  of  equal  length.  The  term  '  fundus  ' 
is  applied  to  that  portion  of  the  body  which  lies  above  the  level 
of  the  attachment  of  the  Fallopian  tubes,  and  is  completely 
covered  by  peritoneum.  In  the  virgin,  its  upper  margin  is  almost 
flat,  and  sometimes  even  presents  a  slight  median  concavity,  but 
in  women  who  have  borne  children  it  is  always  strongly  convex. 
From  the  fundus  down  to  its  connection  with  the  cervix,  the  body 
of  the  uterus  gradually  diminishes  in  its  transverse  diameter. 
The  anterior  and  posterior  walls  are  convex  and  rounded — more 
particularly  the  posterior,  and  are  covered  by  peritoneum.     On 


THE  UTERUS 


4' 


each  side,  at  the  junction  of  the  fundus  and  the  rest  of  the  body, 
are  attached  the  Fallopian  tubes,  and  a  little  below  and  in  front 


Fig.  27. — Vertical  Section  of  Uterus  (Diagrammatic). 

a,  Fundus  uteri ;  b,  corpus  uteri  ;  c,  cervix  ;  d,  os  externum ;  e,  vagina ; 
/,  os  internum.     (Ramsbottom.) 

of  this  point  are  situated  the  uterine  attachments  of  the  round 
ligaments.     The  peritoneum,  which  envelops  the  uterus,  passes 


Fig.  28. — Diagram  to  show  Divisions  of  Cervix. 

c,  Portio  supra-vaginalis  ;  b,  pars  intermedia  ;  a,  portio  infra-vaginalis  ; 
P,  peritoneum  ;  Bl.,  bladder.     (Schroeder.) 

out  from  the  latter  on  both  sides  as  a  double  fold  to  the  lateral 
pelvic  wall,  forming  what  is  called  the  broad  ligament. 


42  OBSTETRICAL  AN  ATOMY— MATERNAL  AND'  OVULAR 

The  cervix  is  the  lower  cylindrical  part  of  the  uterus,  and 
projects  inferiorly  into  the  vagina.  It  is  divided  into  three 
parts,  according  to  their  relations  to  the  vaginal  walls — the  portio 
vaginalis,  the  pars  intermedia,  and  the  portio  supra-vaginalis. 
The  relations  of  these  parts  can  be  clearly  seen  by  referring  to 
the  diagram.  The  supra- vaginal  part  is  covered  posteriorly  by 
peritoneum,  but  in  front  is  in  direct  relation  to  the  bladder- wall, 
the  peritoneum  being  reflected  from  the  uterus  on  to  the  bladder, 
a  little  below  the  level  of  the  isthmus.  The  vaginal  portion 
presents  on  its  inferior  aspect  a  transversely-directed  aperture 
called  the  os  externum,  by  which  the  cavity  of  the  uterus  is 
brought  into  communication  with  the  vaginal  canal.  This 
aperture  is  bounded  by  an  anterior  and  a  posterior  lip,  the 
latter  of  which  is  the  longer  of  the  two,  on  account  of  the  high 
attachment. of  the  vaginal  wall  to  the  uterus  posteriorly. 

Owing  to  the  great  thickness  of  the  uterine  wall,  the  cavity  is 
much  smaller  than  the  size  of  the  organ  itself.  Two  main 
divisions  of  it  can  be  recognised,  corresponding  to  the  body  and 
cervix  respectively.  In  the  upper  part,  the  anterior  and  posterior 
walls  lie  in  contact  with  one  another,  and  thus  cause  the  cavity  to 
be  flattened  antero-posteriorly  and  to  be  triangular  in  shape. 
The  sides  and  base  of  the  triangle  are  somewhat  curved,  with 
the  convexity  directed  inwards  towards  the  cavity.  The  base 
is  directed  upwards,  and  on  each  side  of  it  a  small  diverticulum 
is  prolonged  into  the  Fallopian  tube,  and  communicates  with  the 
canal  of  the  tube  by  means  of  a  very  small  aperture.  The  apex 
of  the  cavity  is  directed  downwards,  and  is  marked  off  from  the 
cavity  of  the  cervix  by  a  constriction,  the  os  internum,  which  is 
situated  at  the  same  level  as  the  isthmus  externally. 

The  cavity  of  the  cervix  extends  from  the  os  internum  to  the 
os  externum.  It  is  wider  in  the  middle  than  at  either  end,  and 
therefore  has  a  fusiform  shape.  The  mucous  membrane  lining 
it  presents  two  well-marked  longitudinal  ridges  situated  on  the 
middle  line  of  the  anterior  and  posterior  walls  respectively.  From 
these  ridges  a  number  of  folds  pass  upwards  and  outwards 
obliquely  on  each  side,  forming  an  appearance  to  which  the  name 
of  arbor  vitae  has  been  applied. 

Dimensions.- — The  dimensions  of  the  uterus  itself  and  of  its 
cavity  vary  within  comparatively  wide  limits,  and  are,  as  a  rule, 
greater  in  women  who  have  borne  children  than  in  nulliparae. 
The  following  measurements  are  given  by  Waldeyer,*  and  may  be 
taken  as  the  average  : — 

*  Waldeyer,  '  Das  Becken,'  p.  496. 


THE  CONNECTIONS  OF  THE   UTERUS 


43 


Length. 

Nulliparae. 

Multipara. 

Entire  uterus 
Corpus  uteri 
Cervix  uteri 
Entire  cavity      - 
Cavity  of  body  - 
Cavity  of  cervix 

2f  in.  (6'5  cm.) 
if  in.  (4-o  cm.) 
i  in.     (2-5  cm.) 
2*  in.  (5'5  cm.) 
ii  in.  (3*0  cm.) 
1  in.     (2 '5  cm.) 

3  in.     (7-5  cm.) 
if  in.  (4-5  cm.) 
if  in.  (3  0  cm.) 
2f  in.  (6*5  cm.) 
if  in.  (4*0  cm.) 
1  in.    (2"5  cm.) 

The  greatest  breadth  of  the  body  is  from  if  to  if  inches  (3-5  to 
4  cm.)  and  the  greatest  thickness  from  1  to  if  inches  (2-5  to 
3  cm.),  in  nulliparae.  In  multiparas,  the  breadth  may  reach  2  inches 
(5  cm.),  and  the  thickness  averages  about  if  inches  (3  cm). 

From  the  above  measurements,  it  will  be  seen  that  the  cavity 
of  the  uterus  is  about  half  an  inch  shorter  than  the  entire  organ 
in  both  nulliparae  and  parous  women,  and  that  the  increase  in 
size,  which  persists  after  pregnancy,  is  accounted  for  by  an 
enlargement  of  the  cavity  rather  than  by  an  increased  thickness 
of  the  uterine  walls. 

It  is  not  until  the  age  of  puberty  is  reached  that  the  uterus 
attains  its  full  size.  Up  to  that  period  of  life  it  develops  very 
slowly,  and  the  cervix  is  of  much  greater  relative  size  than  the 
body.  At  puberty,  however,  rapid  growth  is  established  for  a 
time,  and  especially  in  the  body,  so  that  the  full  adult  form  is 
quickly  attained.  The  uterus  of  a  virgin  usually  weighs  about 
an  ounce,  in  multiparas  it  is  slightly  heavier. 

The  Connections  of  the  Uterus. — The  uterus  may  be  regarded  as 
being  slung  in  the  pelvic  cavity  by  means  of  the  broad  ligaments. 
These  ligaments  are  double  folds  of  peritoneum,  which  pass  from 
the  lateral  margins  of  the  uterus  to  the  pelvic  wall,  and  which 
contain  between  their  layers  the  Fallopian  tube  or  oviduct,  the 
ovary,  the  parovarium,  the  paroophoron,  the  round  ligament,  and 
the  uterine  and  ovarian  vessels,  nerves,  and  lymphatics.  The 
upper  margin  of  each  ligament  is  free,  and  here  the  two  layers 
become  continuous  with  one  another  above  the  oviduct.  Below, 
the  ligament  is  fixed  by  its  connections  with  the  pelvic  fascia,  and 
externally  the  two  layers  which  form  it  are  continuous  with  the 
peritoneum  which  lines  the  lateral  aspect  of  the  pelvic  cavity  and 
which  passes  upwards  into  the  abdomen.  These  ligaments  are 
somewhat  lax,  and  allow  slight  movement  of  the  uterus  to  either 
side.  The  other  peritoneal  ligaments  of  the  uterus  are  the  two 
anterior  or  utero-vesical,  and  the  two  posterior  or  utero-sacral ; 
along  with  these  the  round  ligaments,  though  of  a  different  nature, 
may  be  described. 

The  anterior  ligaments  are  two  slight  and  unimportant  folds  of 
peritoneum,  which  pass  from  the  cervix  uteri  to  the  posterior 
aspect  of  the  bladder.  They  form  the  lateral  extremities  of  the 
reflection  of  the  peritoneum  from  the  uterus  on  to  the  bladder, 


44         OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 

and  bound  the  utero- vesical  pouch  on  each  side.*  The  utero- 
sacral  ligaments  are  also  folds  of  peritoneum  passing  from  the 
posterior  aspect  of  the  lower  part  of  the  corpus  uteri  back- 
wards to  the  sides  of  the  rectum,  at  about  the  level  of  the 
third  sacral  vertebra,  and  bounding  the  pouch  of  Douglas,  or 
recto-vaginal  pouch,  on  each  side.  They  are  much  more  strongly 
developed  than  the  anterior  ligaments,  and  contain  between  their 
layers  a  considerable  quantity  of  unstriped  muscular  tissue,  which 
by  its  contraction  probably  plays  an  important  part  in  enabling 
the  uterus  to  adapt  its  position  to  changes  in  the  size  of  adjoining 
viscera.  The  round  ligaments  are  attached  to  the  corpus  uteri 
just  below  and  in  front  of  the  Fallopian  tubes.  They  are  flattened 
muscular  cords,  the  fibres  of  which  are  continuous  with  the 
external  layer  of  longitudinal  muscle  fibres  of  the  uterine  wall, 
and  are  surrounded  by  an  irregular  mass  of  involuntary  muscle 
fibres.  Commencing  at  the  uterus,  they  pass  on  each  side 
upwards,  outwards,  and  forwards  in  a  fold  of  the  anterior  layer 
of  the  broad  ligament  to  the  internal  abdominal  ring,  and  having 
traversed  the  inguinal  canal,  they  terminate  in  the  subcutaneous 
tissue  of  the  labium  majus.  They  probably  exercise  some  influence 
in  drawing  the  uterus  forwards. 

The  Position  of  the  Uterus. — Owing  to  the  small  size  of  the  pelvis, 
the  uterus  in  the  fcetus,  and  for  some  time  after  birth,  lies  above 
the  brim  of  the  pelvis,  and  is  in  the  greater  part  of  its  extent  an 
abdominal  organ.  During  growth,  it  gradually  sinks,  and  about 
the  tenth  year  of  life  it  reaches  its  adult  position,  with  the  upper 
margin  of  the  fundus  at  the  level  of  the  pelvic  brim.  It  has  been 
stated  that  the  uterus  may  be  regarded  as  being  slung  in  the 
pelvis  by  the  two  broad  ligaments.  Owing  to  the  laxity  of  these 
ligaments  and  the  other  folds  of  peritoneum  which  are  attached 
to  it,  it  is  freely  movable  in  an  antero-posterior  direction  around  a 
transverse  axis  passing  through  the  lower  border  of  the  broad 
ligaments  about  the  level  of  the  isthmus.  It  is  also  capable  of 
movement,  though  to  a  less  extent,  in  a  lateral  direction.  These 
movements  are  normal,  and  are  chiefly  determined  by  the  degree 
of  distension  of  the  bladder  and  rectum.  When  both  these 
viscera  are  moderately  distended,  the  long  axis  of  the  uterus  is 
usually  found  to  be  parallel  to  the  axis  of  the  pelvic  brim,  and 
therefore  almost  at  right  angles  to  the  axis  of  the  vagina.  The 
fundus  is  directed  upwards  and  forwards,  and  the  anterior  wall 
lies  in  contact  with  the  bladder.  As  the  bladder  gradually  fills, 
the  uterus  is  driven  upwards  and  backwards,  and,  turning  upon 
its  transverse  axis,  assumes  a  vertical  position.  In  cases  of 
extreme  distension  of  the  bladder,  the  uterus  may  even  become 
retroverted.  When  the  bladder  is  quite  empty,  the  fundus  and 
body  of  the  uterus  lie  upon  its  upper  surface,  and  the  corpus  uteri 

*  It  would  perhaps  be  more  correct  to  describe  only  one  utero-vesical  liga- 
ment, and  to  define  it  as  the  peritoneum  reflected  from  the  uterus  on  to  the 
back  of  the  bladder. 


THE  STRUCTURE  OF  THE   UTERUS  45 

makes  a  distinct  angle  with  the  cervix.  It  is  important  therefore 
to  bear  in  mind  that  the  uterus  is  essentially  a  mobile  organ,  the 
movements  being  for  the  most  part  passive,  and  depending  upon 
the  different  external  pressures  to  which  it  is  subjected.  It  cannot 
therefore  be  said  to  have  any  one  normal  position. 

The  Structure  of  the  Uterus. — The  uterine  wall  is  composed  of  an 
outer  serous,  a  middle  muscular,  and  an  internal  mucous  coat. 

The  serous  coat,  composed  of  the  peritoneal  covering  of  the 
uterus,  has  already  been  sufficiently  dealt  with.  It  is  bound  to  the 
muscular  coat  by  a  thin  layer  of  connective  tissue — the  para- 
metrium, which  is  continuous  with  the  areolar  tissue  contained 
between  the  layers  of  the  broad  ligament.  This  connective  tissue 
is  more  abundant  at  the  sides  and  in  front  than  elsewhere. 

The  muscular  coat  is  nearly  a  quarter  of  an  inch  thick.  It  is 
composed  of  involuntary  muscular  tissue,  most  of  the  fibres  of 
which  are  of  small  size.  In  the  non-gravid  uterus,  these  fibres 
are  so  closely  interwoven  and  bound  together  by  connective 
tissue  that  it  is  very  difficult  to  distinguish  any  layers.  During 
pregnancy,  however,  the  muscle  fibres  themselves  become  hyper- 
trophied,  and  the  bands  which  they  form  becoming  more 
differentiated,  it  is  usually  possible  to  distinguish  three  different 
strata.  The  most  superficial  of  these  strata,  according  to  some 
authorities,"  is  the  only  representative  of  the  muscular  coat 
proper,  all  the  rest  forming  a  greatly  hypertrophied  muscularis 
mucosae.  It  is  composed  of  longitudinally  running  bundles, 
which,  commencing  at  the  cervix,  arch  over  the  fundus.  On 
each  side  it  sends  off  some  fibres  into  the  broad  ligament,  the 
uppermost  of  which  pass  to  the  inferior  pole  of  the  ovary  and 
constitute  the  ovarian  ligament.  From  this  layer  also  are  derived 
the  fibres  of  the  round  ligament.  The  middle  stratum  forms  the 
principal  mass  of  the  muscular  coat,  and  is  composed  of  fibres 
which  interlace  closely  with  one  another,  running  both  in  a 
transverse  and  an  oblique  direction,  while  the  internal  stratum  is 
formed  of  circular  fibres.  Above,  the  last  named  is  continuous 
with  the  circular  fibres  of  the  Fallopian  tubes,  and  below,  it 
becomes  aggregated  into  bundles  which  form  sphincter  muscles 
for  both  the  os  internum  and  the  os  externum.  In  the  cervix, 
the  muscular  tissue  is,  according  to  Waldeyer,t  much  less  com- 
pact than  elsewhere,  and  there  is  a  layer  of  longitudinally 
running  fibres  internal  to  the  transverse  ones. 

The  mucous  membrane  of  the  uterus  is  directly  connected  with 
the  innermost  layer  of  the  muscular  coat  without  the  intervention 
of  a  submucous  layer.  That  which  lines  the  body  of  the  uterus 
is  soft  and  smooth,  and  in  the  intervals  between  the  menstrual 
periods  is  about  a  millimetre  in  thickness.  It  is  composed  of 
connective  and  elastic  tissue,  the  fibres  of  which  unite  to  form 

*  Williams,  John,  Trans.  Obst.  Society,  vol.  xxvii. 
+  Waldeyer,  '  Das  Becken,'  p.  468. 


46 


OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 


a   meshwork  of  lymph   sinuses.     Scattered  throughout  it,  also, 
are  found  numerous  lymphoid  cells.     It  is  covered  by  a  layer  of 


Fig.    29.  —Section   of   the   Mucous   Membrane   of   the   Body    of    the 

Uterus     at     the    Commencement     of     Pregnancy,     showing     the 
Uterine  Glands.     (Galabin.) 


Fig.  30. — Blood-supply  of  Uterus,  Ovary,  and  Fallopian  Tubes 

(Anterior  View). 

Ur.,  ureter  ;   U.  A.,  uterine  artery  ;  U.V.,  uterine  vein  ;   O.A. ,  ovarian  artery; 
O. V.,  ovarian  vein.     (Kelly.) 

columnar  ciliated  epithelium,  and  opening  on  its  surface  are  the 
orifices  of  numbers  of  minute  glands  which  lie  embedded  in  its 
substance.     These  glands  are,  for  the  most   part,  simple  tubes, 


THE   UTERINE  BLOODVESSELS  AND  LYMPHATICS 


47 


lined  by  a  layer  of  ciliated  epithelium  continuous  with  and  similar 
to  that  which  lines  the  cavity,  and  supported  by  a  slender  base- 
ment membrane.  They  extend  throughout  the  whole  depth  of 
the  mucous  membrane,  and  sometimes  have  their  bases  placed 
amid  the  innermost  fibres  of  the  muscular  coat.  Most  of  them 
run  rather  obliquely,  but  some  pass  directly  outwards. 

The  mucous  membrane  of  the  cervix  differs  from  that  of  the 
body  in  being  much  firmer  and  more  closely  adherent  to  the  sub- 
jacent tissue,  and  a  sharp  line  of  demarcation  exists  between  the 
two.  The  upper  portion  of  the  cervix  is  lined  by  ciliated  epithe- 
lium, and  contains  within  its  substance  numerous  tubular  and 
acinous  glands,  the  ducts  of  which  open  upon  its  surface.  The 
extreme  lower  portion  is  lined  with  squamous  epithelium  continued 


Fig.  31. — Diagram  of  Blood-supply  of  Uterus  and  Annexa. 

Ov.  a.,  ovarian  artery;  Ut.  a.,  uterine  artery.  Note  the  free  anastomosis 
between  the  ovarian  and  uterine  arteries  in  the  neighbourhood  of  the 
fundus  uteri.     (Williams.) 

in  through  the  os  externum,  and  possesses  no  glands.  The 
peculiar  arrangement,  which  gives  rise  to  the  appearance  known 
as  the  arbor  vitae,  has  been  already  described. 

The  Uterine  Bloodvessels  and  Lymphatics. — The  principal  arteries 
of  supply  to  the  uterus  are  the  uterine,  which  come  one  at  each 
side  from  the  anterior  division  of  the  internal  iliac  vessels,  and 
pass  downwards  and  inwards  in  the  broad  ligament  to  the  cervix. 
Here,  they  give  off  a  few  small  twigs  to  the  vagina,  and  then 
turn  upwards  along  the  lateral  border  of  the  uterus  and  anasto- 
mose near  the  fundus  with  branches  from  the  ovarian  arteries. 
These  last-named  vessels  form  a  large  part  of  the  blood-supply 
to  the  fundus.  The  course  of  the  uterine  arteries  by  the  side  of 
the  uterus  is  very  tortuous,  and  as  they  pass  upwards  they  give 


48 


OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 


off  numerous  branches  which  pursue  an  almost  transverse  course 
on  the  anterior  and  posterior  uterine  wall.  These  transverse 
branches  are  also  tortuous,  and  are  placed  in  a  special  layer  of 
connective  tissue  deep  to  the  external  longitudinal  muscular 
layer.*  From  them,  twigs  are  given  off  which  pass  vertically 
inwards  and  end  in  the  mucous  membrane  in  a  capillary  plexus 
draining  itself  into  thin-walled  veins  devoid  of  valves.  These 
veins  gradually  unite  into  branches  corresponding  to  the  arteries, 


Fig.  32  — Lymphatics  of  the  Pelvic  Organs.     (Kelly.) 


and  form  what  are  known  in  the  gravid  uterus  as  the  uterine 
sinuses.  The  larger  branches  communicate  with  a  venous  plexus 
lying  in  the  broad  ligament,  and  are  ultimately  drained  by  the 
uterine  and  ovarian  veins. 

The  lymphatics  of  the  uterus  are  arranged  in  three  distinct 
plexuses  which  communicate  with  one  another,  one  being  situated 
in  the  mucous  coat,  to  which  reference  has  already  been  made,  one 
in   the  muscular  coat,  and  one  beneath  the  serous  coat.     The 

*  Williams,  loo.  cit. 


THE  NERVES  OF  THE   UTERUS 


49 


vessels  arising  from  them  drain  their  lymph  into  the  lumbar  and 
hypogastric  glands. 

The  Nerves  of  the  Uterus. — According  to  most  authorities  there  is 
a  centre  for  uterine  movement  situated  in  the  lumbar  region  of  the 
spinal  cord.  The  fibres  from  this  centre  emerge  by  the  third,  fourth, 
and  fifth,  lumbar  nerves  and  possibly  from  some  sacral  nerves  and 


Fig.  33. — Nerves  of  the  Uterus. 
1,  Right  ganglion  cervicis  ;   2,   right  hypogastric  plexus;  3,  uterine  plexus; 
4,  5,   6,   lumbar  sympathetic;    7,   solar  ganglion;    8,  9,  renal   ganglia; 
10,  ii,  genital  ganglia;   12,  13,  ovarian  plexus.     I.,  II.,  III.,  IV.,  lumbar 
vertebrae.     (Bumm.) 

communicate  with  the  pelvic  plexuses  of  the  sympathetic.  Nerves 
composed  of  mixed  cerebro-spinal  and  sympathetic  fibres  then 
pass  between  the  folds  of  the  utero-sacral  and  broad  ligaments 
to  the  uterus,  where  they  communicate  with  a  large  ganglion,  or 
rather,  series  of  small  ganglia,  situated  on  the  posterior  aspect 

4 


5° 


OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 


and  sides  of  the  cervix  uteri — the  cervical  ganglion.  From  this 
ganglion,  fibres  are  distributed  to  the  whole  uterus,  including 
the  cervix,  arid  some  of  these  terminate  in  muscle  cells.  It  is 
uncertain  whether  any  branches  pass  directly  to  the  uterus  with- 
out first  communicating  with  the  cervical  ganglion.  Many  of  the 
nerve  fibres  are  destined  for  the  supply  of  the  bloodvessels,  but 
without  doubt  some  control  the  uterine  contractions,  for  if  the 
lumbar  centre  be  destroyed  all  power  of  parturition  is  abolished. 
Stimulation  of  the  nerves,  moreover,  produces  powerful  uterine 
and  vaginal  contractions. 

The  Fallopian  Tubes. — The  Fallopian  tubes  or  oviducts  are  the 
muscular  canals  through  which  the  ovum  passes  on  its  way  to  the 
uterus.     They  pass  out  from  the  superior  angle  of  the  lateral 


Fig.  34. — Section  through  Isthmus  of  Fallopian  Tube. 

A,  Submucous  layer  ;  B,  ciliated  epithelium  ;  C,  circular  muscle 
fibres  ;  D,  longitudinal  muscle  fibres.     (Macalister.) 


border  of  the  uterus  in  the  upper  free  border  of  the  broad  liga- 
ment for  a  distance  of  from  four  to  five  inches.  On  first  leaving  the 
uterus,  they  pursue  a  horizontal  course,  lying  on  the  pelvic  floor, 
till  they  reach  the  lateral  pelvic  wall,  when  they  turn  upwards  and 
pass  in  a  rather  tortuous  manner  along  the  anterior  border  of  the 
ovary,  till,  reaching  its  superior  pole,  they  terminate  by  spreading 
out  on  its  superior  and  inner  aspect.  Each  tube  may  be  divided 
into  three  portions,  an  interstitial  part  lying  between  the  layers  of 
the  uterine  wall,  an  isthmus,  and  an  ampulla.  The  intra-uterine  or 
interstitial  portion  is  about  half  an  inch  in  length,  and  communicates 
with  the  cavity  of  the  uterus  by  means  of  a  very  minute  orifice, 
the  ostium  internum,  which  in  the  healthy  state  will  hardly  admit 
the  passage  of  a  bristle.     The  part  immediately  succeeding  this, 


THE  FALLOPIAN  TUBES 


51 


and  forming  about  the  inner  third  of  the  free  portion  of  the  tube, 
is  round  and  cord-like,  and  has  received  the  name  of  the  isthmus 
on  account  of  its  extremely  small  lumen,  which  does  not  exceed 
two  millimetres  in  diameter.  The  outer  two-thirds  of  the  tube  is 
much  wider,  its  lumen  having  a  diameter  of  about  six  millimetres. 
It  is  hence  known  as  the  ampulla,  and  constitutes  that  portion  of 
the  tube  which  is  in  relation  to  the  ovary.  It  terminates  in  a 
somewhat  bell-shaped  manner  by  expanding  to  surround  its 
orifice,  the  ostium  abdominale,  which  opens  into  the  peritoneal 
cavity.     This  orifice  is  kept  closed  during  life,  as  is,  indeed,  the 


FiGi  32. — Transverse  Section  of  Ampulla  of  Fallopian  Tube,  showing 
the   Complicated   Arrangement  of   the   Longitudinal   Plications 

WHICH    ARE    HERE    CUT    ACROSS.       (Ahlfeld.) 


whole  extent  of  the  ampulla,  by  the  tonic  contraction  of  the 
muscular  walls  of  the  tube,  and  is  surrounded  by  a  number  of 
fimbriae,  one  of  which  is  attached  to  the  superior  pole  of  the 
ovary,  and  has  received  the  special  name  of  the  ovarian  fimbria. 

In  addition  to  a  thin  peritoneal  covering,  the  tubes  possess  a 
muscular  and  a  mucous  coat.  The  muscular  coat  is  composed  of 
an  outer  layer  of  longitudinal  and  an  inner  layer  of  circular  fibres, 
which  are  continuous  respectively  with  the  outer  and  inner  layers 
of  the  muscular  wall  of  the  uterus.  The  mucous  membrane 
and  the  fimbriae  are  covered  by  a  layer  of  ciliated  epithelium, 

4—2 


52  OBSTETRICAL  ANATOMY—MATERNAL  AND  OVULAR 

the  ciliae  of  which  produce  a  current  in  the  direction  of  the  uterus, 
and  which  was  supposed  to  exercise  an  important  function  in 
propelling  the  ovum  into  the  uterine  cavity.  In  transverse  sections 
through  the  tube  it  is  seen  that  the  mucous  membrane  is  thrown 
into  a  series  of  longitudinal  folds  by  the  contraction  of  .its  walls. 
These  folds  are  best  marked  in  the  outer  part  of  the  tube,  and 
they  entirely  disappear  when  the  canal  is  distended  with  injection. 

The  blood-supply  of  the  tubes  is  derived  from  the  uterine  and 
ovarian  vessels. 

The  Ovaries.  —  The  ovaries  are  two  small,  somewhat  oval, 
bodies,  situated  one  on  each  side  of  the  pelvic  cavity,  in  a  special 
fold  of  the  posterior  layer  of  the  broad  ligament.  In  size,  they 
have  been  compared  to  almonds,  and  they  weigh  in  the  adult  from 
6  to  8  grammes.      They  measure  from  3    to    5  centimetres  in 


Fig.  36. — Diagram  of  Uterus  and  Appendages. 

od,  Fallopian  tube  ;  i,  ampulla  of  tube  ;  fi,  fimbriated  end  of  tube ;  0,  ovary  ; 
po,  parovarium  ;  v,  vagina  ;  u  and  c  are  placed  on  the  upper  and  lateral 
uterine  walls  respectively  ;  I,  round  ligament ;  lo,  uterine  ligament  of 
ovary.     (Quain.) 

length,  from  i|  to  3  centimetres  in  breadth,  and  from  a  half  to 
ii-  centimetres  in  thickness  (Waldeyer*).  In  the  full-term  foetus 
they  are  much  larger  in  proportion  to  the  size  of  the  body  than 
in  the  adult,  and  are  situated  almost  completely  above  the  pelvic 
brim  in  the  iliac  fossae.  They  gradually  descend  during  growth, 
and  in  the  adult  virgin  are  found  lying  in  relation  to  the  posterior 
part  of  the  lateral  pelvic  wall,  immediately  anterior  to  the  internal 
iliac  arteries  and  external  to  the  utero-sacral  ligament.  Most 
recent  observers  state  that  their  long  axis  is  directed  vertically. 
They  are  flattened  from  side  to  side,  and  present  for  examination 
an  anterior  and  a  posterior  border,  an  outer  and  an  inner  surface, 
and  an  upper  and  lower  pole. 

The  anterior  border  is  known  as  the  hilus.     It  receives  the 
ovarian  vessels  and  nerves,  and  is  fixed  by  these  to  the  broad 

*  Waldeyer,  '  Das  Becken,'  p.  521. 


THE  OVARIES 


53 


ligament.  The  posterior  border,  together  with  the  outer  and 
inner  surface,  is  free,  and  is  covered  by  a  layer  of  columnar 
epithelium,  which  must  be  regarded  as  modified  peritoneum. 
The  relation  of  the  Fallopian  tube  to  the  two  borders  and  to  the 
inner  surface  has  already  been  described.  The  outer  surface  is 
in  relation  to  the  peritoneum  lining  the  lateral  pelvic  wall.  The 
superior  pole  is  known  as  the  tubal  pole,  owing  to  its  attachment 
to  the  ovarian  fimbria.  Passing  from  it  to  the  lateral  pelvic 
wall,  there  is  a  special  fold  of  peritoneum — the  ovario-pelvic  liga- 
ment. The  inferior,  or  uterine,  pole  is  directed  downwards,  and 
is  connected  to  the  lateral  border  of  the  uterus  by  means  of  a 
muscular  band,  derived  from  the  longitudinal  muscle  fibres  of 
the  uterine  wall,  and  called  the  ovarian  ligament. 

The  ovary,  as  well   as  the  uterus,  must  be  regarded  as  an 


Fig.  37. — Vertical  Section  through  Broad  Ligament. 

A,  Fallopian  tube;  B,  tubal  branch  of  ovarian  vessels;  C,  parovarium; 
D,  ovarian  artery;  E,  round  ligament;  F,  connective  tissue;  G,  uterine 
veins  ;  H,  uterine  artery  ;  I,  ovary  ;  J,  ureter  ;  K,  peritoneum. 
(Anderson.) 


essentially  movable  organ,  its  position  depending  largely  upon 
that  of  the  uterus.  It  is  greatly  displaced  during  pregnancy,  and 
never  regains  its  original  position. 

Structure  of  the  Ovary. — In  order  that  the  structure  of  the  ovary 
may  be  understood,  it  is  necessary  to  refer  briefly  to  the  method 
of  its  development. 

When  transverse  sections  are  made  through  the  embryo  of  a 
chick  at  about  the  second  day  an  accumulation  of  mesoblastic 
tissue  is  found  lying  on  each  side  of  the  mesial  plane,  between 
the  lateral  plates  and  paraxial  portions  of  the  mesoblast.  This 
is  called  the  intermediate  cell  mass,  and  it  is  within  it  that  the 
ovary  and  primitive  kidney  is  formed.  The  inner  portion  of  this 
mesoblast  is  early  raised  up  into  a  definite  ridge — the  genital 
ridge,  and  is  covered  by  a  thick  layer  of  hypoblast — the  germinal 
epithelium.     Some  of  the  cells  of  this  epithelium  are  larger  than 


54 


OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 


others,  and  are  known  as  the  primordial  ova.  Very  soon,  out- 
growths of  this  epithelial  layer  begin  to  extend  into  the  subjacent 
mesoblast,  and  become  arranged  in  such  a  manner  that  the  prim- 
ordial ova  are  surrounded  by  a  layer  of  the  undifferentiated  cells. 
These  downgrowths  soon  become  separated  from  the  surface,  and 


Fig.  38. — Section  through  Part  of  Ovary  of  Adult  Bitch. 

Germinal  epithelium  ;  b,  b,  ingrowths  (egg-tubes)  from  the  germinal 
epithelium,  seen  in  cross-section  ;  c,  c,  young  Graafian  follicles  in  the 
cortical  layer  ;  d,  a  more  mature  follicle,  containing  two  ova  (this  is  rare) ; 
e  and  /,  ova  surrounded  by  cells  of  discus  proligerus  ;  g,  h,  outer  and 
inner  capsules  of  the  follicle ;  i,  membrana  granulosa  ;  I,  bloodvessels ; 
m,  m,  parovarium ;  g,  germinal  epithelium  commencing  to  grow  in  and 
form  an  egg- tube  ;  z,  transition  from  peritoneal  to  germinal  epithelium. 
(Waldeyer.) 


form  the  primitive  Graafian  follicles  embedded  in  mesoblast,  from 
which  the  stroma  of  the  ovary  is  formed.  The  rudiment  of  the 
ovary  lies  at  first  within  the  abdomen  on  the  psoas  muscle,  im- 
mediately below  the  kidney,  but  it  is  gradually  moved  down- 
wards, and  finally  takes  up  its  position  within  the  pelvis. 

When  sections  are  made  through  the  mature  ovary,  appear- 


THE  OVARIES 


55 


ances  are  seen  which  correspond  with  the  method  of  develop- 
ment. It  is  composed  of  an  inner  medullary  and  an  outer  cortical 
portion,  and  is  covered  by  a  layer  of  columnar  epithelium  con- 
tinuous with  the  peritoneum.  The  medulla  is  composed  of  rather 
loosely-arranged  bundles  of  fibrous  and  elastic  tissue,  and  contains 
the  large  bloodvessels  and  nerves  which  have  passed  into  it  from 
the  hilus.  There  is  no  sharp  line  of  demarcation  between  the 
cortex  and  the  medulla,  as  the  latter  sends  out  processes  of 
connective  tissue,  which  extend  in  a  radial  manner  into  the 
cortex,  conveying  the  bloodvessels  and  nerves,  and  blending  with 
the  stroma  of  that  portion  of  the  organ.  The  cortex  is  composed 
of  two  portions — the  stroma,  which  is  chiefly  mesoblastic  in 
origin,  and  the  ova,  lying  in  the  Graafian  follicles.     The  stroma 


Fig,  39. — A,  Recently  Ruptured  Graafian  Follicle. 
Graafian  Follicle,  showing  Stigma. 


B,  Normal 


(Micro-photographs  prepared  by  McConnell  and  J.  C.  Hirst.) 


constitutes  the  great  bulk  of  the  organ,  and  is  largely  composed 
of  spindle-shaped  connective-tissue  cells,  arranged  in  bundles  so 
as  to  form  a  supporting  network  for  the  follicles.  In  addition  to 
these  cells,  however,  it  also  contains  a  number  of  polyhedral  cells, 
supposed  to  be  epithelial  in  nature,  and  which  are  sometimes 
credited  with  the  formation  of  a  hypothetical  internal  secretion. 
Immediately  beneath  the  epithelium  which  covers  the  ovary  the 
stroma  contains  no  ova,  and  forms  a  condensed  fibrous  layer  called 
the  tunica  albuginea.  In  the  superficial  layers  of  the  cortex,  im- 
mediately under  the  tunica  albuginea,  only  immature  ova  are 
found,  surrounded  by  a  single  layer  of  cells,  which  alone-  separates 
them  from  the  stroma  ;  but  a  little  deeper  the  ova  themselves  are 
found  to  be  of  larger  size,  and  the  cells  surrounding  them  are 
increased  in   number,   so  as  to  form  an   envelope  composed   of 


56  OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 

several  layers  of  cells,  the  outer  and  inner  layers  of  which  have 
taken  on  a  columnar  character.  Lying  outside  the  external  layer 
of  columnar  cells  is  a  definite  fibrous  membrane,  which  separates 
the  entire  structure  from  the  general  stroma,  and  which  contains 
capillary  bloodvessels  in  its  inner  portion.  The  complete  struc- 
ture contained  within  this  limiting  membrane  is  called  a  Graafian 
follicle. 

As  growth  proceeds,  the  cells  surrounding  the  ovum  still  further 
increase  in  number,  and,  with  the  exception  of  the  outer  and 
inner  layer,  become  polygonal  in  shape,  as  a  result  of  mutual 
pressure.  Still  later,  fluid  is  effused  into  the  midst  of  the  cells 
separating  them  into  an  outer  and  an  inner  layer,  called  re- 
spectively the  membrana  granulosa  and  the  discus  proligerus. 
The  two  layers  always,  however,  remain  continuous  with  one 
another  at  one  part  of  the  follicle.  The  fluid  which  separates  the 
cells  is  called  the  liquor  folliculi.  The  Graafian  follicle  now 
presents  the  following  structures  from  without  inwards  : — - 

i.  The  basement  membrane  or  theca,  composed  of  an  outer 
fibrous  and  an  inner  vascular  layer. 

2.  A  boundary  layer  of  columnar  cells. 

3.  The  membrana  granulosa. 

4.  The  liquor  folliculi. 

5.  The  discus  proligerus. 

6.  The  ovum. 

An  account  of  the  ovum  will  be  given  in  the  next  chapter, 
which  deals  with  its  development. 

While  the  above-described  changes  are  going  on  within  it,  the 
Graafian  follicle  is  gradually,  owing  to  its  distension,  approach- 
ing the  surface  of  the  ovary,  and  on  reaching  this  it  bursts ;  the 
ovum  is  expelled  into  the  peritoneal  cavity,  and  the  liquor  folliculi 
escapes.  The  rupture  of  follicles  in  this  manner  accounts  for  the 
scars  which  are  found  on  the  serous  covering  of  the  ovary  after 
puberty. 

Corpus  Luteum. — The  rupture  of  the  Graafian  follicle  probably 
coincides  with  the  date  of  the  menstrual  flow,  and  is  doubt- 
less aided  by  the  general  congestion  of  the  reproductive  organs 
which  occurs  at  that  time.  After  rupture,  the  walls  of  the 
empty  follicle  contract  and  come  in  contact  with  one  another. 
The  inner  layer  of  the  theca  is  less  contractile  than  the  outer, 
and  is  therefore  thrown  into  a  series  of  folds.  Proliferation  of  the 
cells  of  the  membrana  granulosa  then  occurs,  and  gradually  fills 
up  the  interior  of  the  follicle  and  the  cavity  left  on  the  surface  of 
the  ovary  by  its  rupture.  A  small  amount  of  the  space  left  by 
the  rupture  is  also  filled  up  by  some  blood-clot  which  has  been 
extravasated  at  that  time.  During  the  same  period,  small  tufts  of 
bloodvessels  accompanied  by  fibrous  tissue  grow  in  towards  the 
centre  of  the  follicle  from  the  inner  layer  of  the  limiting  mem- 
brane. The  entire  structure,  composed  of  blood-clot,  proliferated 
epithelial  cells,  vascular  loops,  and  fibrous  tissue,  is  known  as  the 


THE  UTERUS 


57 


corpus  luteum,  this  name  being  given  on  account  of  the  presence 
of  a  yellowish  pigment  within  the  cells.  Growth  goes  on  for  a 
period  of  about  three  weeks  within  the  corpus  luteum,  but  after 
this  time  the  cells  cease  to  proliferate,  and  begin  to  break  down 
into  a  yellowish  detritus,  while  at  the  same  time  the  fibrous 
tissue  encroaches  more  and  more  on  the  cellular  part  and  reaches 
the  centre  of  the  structure.  Absorption  of  the  broken  -  down 
matter  now  commences,  and  after  a  period  of  two  months  from 
the  date  of  rupture  nothing  is  left  of  the  corpus  luteum  but  a 
fibrous  scar. 

The  above  is  the  normal  course  of  events  in  cases  in  which 
conception  has  not  occurred,  but  when  pregnancy  supervenes 
upon  the  discharge  of  the  ovum  the  corpus  luteum  attair  s  a  larger 
size.  It  continues  to  grow  till  the  third  or  fourth  month  ;  its 
walls  are  thicker  and  its  colour  a  much  brighter  yellow.    Absorp- 


Fig.  40. — -The  Corpus  Luteum  at  the  End  of  Pregnancy.     (Dalton.) 

tion  also  occurs  slowly,  so  that  at  the  end  of  pregnancy  it  may 
still  have  a  diameter  of  from  8  to  10  millimetres.  The  corpus 
luteum  of  pregnancy  is  sometimes  called  the  true  corpus  luteum, 
in  contradistinction  to  that  of  menstruation,  which  is  called  the 
false  corpus  luteum.  The  increased  size,  which  the  former  attains, 
may  be  associated  with  the  greatly  increased  blood-supply  to 
the  pelvic  organs  during  pregnancy. 


THE  REMAINING  PELVIC  ORGANS 

A  very  brief  description  of  the  intra-pelvic  portion  of  the  ureter, 
of  the  bladder,  and  of  the  rectum  will  now  be  given  in  order  that 
the  relation  of  these  viscera  to  the  pelvic  floor  and  to  the  genital 
organs  may  be  understood. 

The  Ureters. — The  ureter  enters  the  pelvis  by  crossing  the 
common  iliac  artery  close  to  its  bifurcation,  and  turns  downwards 


58         OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 

and  inwards  in  front  of  the  internal  iliac  vessels.  Reaching  the 
inner  side  of  this  artery  about  the  level  of  the  upper  margin  of 
the  fourth  sacral  vertebra,  it  turns  forwards  in  relation  to  the 
outer  pelvic  wall,  from  which,  however,  it  is  separated  by  a 
quantity  of  lcose  connective  tissue.  On  its  way  forwards,  it  passes 
under  cover  of  the  lower  border  of  the  broad  ligament,  at  which 
place  it  is  crossed  by  the  uterine  artery  and  vein,  and  comes  into 
relation  with  the  lateral  fornix  of  the  vagina  at  the  point  where 
the  vaginal  wall  blends  with  the  cervix  uteri.  Finally,  it  turns 
forwards,  inwards,  and  downwards  around  the  lateral  vaginal 
wall  to  enter  the  posterior  aspect  of  the  bladder. 

The  Bladder. —  The  bladder  in  the  semi-distended  state  is  tetra- 
hedral  in  form,  with  its  long  axis  directed  antero-posteriorly. 
The  apex  lies  in  relation  to  the  anterior  abdominal  wall  just  above 
the  symphysis  pubis.  The  base  is  directed  backwards  and  is 
almost  vertical  in  direction.  Above,  the  base  is  separated  from  the 
uterus  by  the  utero- vesical  pouch  of  peritoreum,  while,  below,  it 
is  in  direct  relation  to  the  anterior  uterine  wall  and  to  the  anterior 
wall  of  the  vagina,  forming  with  the  latter  the  vesico-vaginal 
septum.  The  superior  surface  of  the  bladder  forms  a  horizontal 
shelf  in  the  pelvis,  upon  which  the  fundus  uteri  and  some  coils  of 
small  intestine  are  supported.  Inferiorly,  the  bladder  lies  in  contact 
with  the  symphysis  pubis  and  retropubic  pad  of  fat  near  the 
mesial  plane,  and  laterally  is  supported  by  the  anterior  fibres  of 
the  levator  ani  muscle  (pubo-coccygeus  muscle). 

The  Rectum. — The  rectum  is  continuous  superiorly  with  the 
pelvic  colon.  It  constitutes  that  part  of  the  large  intestine  which 
is  fixed  within  the  cavity  of  the  true  pelvis,  and  for  descriptive 
purposes  is  divided  into  two  stages.  The  first  stage  commences 
a  little  to  the  right  of  the  mesial  plane  at  the  level  of  the  third 
sacral  vertebra,  and  terminates  one  inch  beyond  the  tip  of  the 
coccyx.  It  follows  the  curve  of  the  sacrum,  the  coccyx,  and  the 
ano-coccygeal  body  throughout,  and  is  in  relation  posteriorly  to 
these  structures.  In  front,  this  stage  is  covered  with  peritoneum 
as  far  down  as  the  level  of  the  fifth  piece  of  the  sacrum,  at  which 
point  the  peritoneum  leaves  it,  and  is  reflected  on  to  the  posterior 
vaginal  wall,  forming  the  recto- vaginal  pouch.  Below  this,  the 
anterior  wall  of  the  rectum  is  in  direct  relation  with  the  posterior 
aspect  of  the  vagina  and  with  the  perinatal  body.  On  each  side 
the  rectum  is  covered  by  peritoneum  above,  and  is  supported  by 
the  levator  ani  muscle  below.  The  second  stage  commences  at  a 
point  an  inch  beyond  the  tip  of  the  coccyx,  and  passes  almost 
directly  backwards  to  the  anus,  so  that  its  axis  forms  nearly  a 
right  angle  with  the  axis  of  the  first  stage.  It  is  known  as  the 
anal  canal,  or,  on  account  of  the  muscles  by  which  it  is  sur- 
rounded, as  the  sphincteric  zone  of  the  rectum.  Above  and 
behind,  it  is  in  relation  to  the  ano-coccygeal  body,  and  below  and 
in  front,  it  is  separated  from  the  vagina  by  the  triangular  perinaeal 
body. 


THE  PERINJEUM  59 


THE  PELVIC  FLOOR  AND  MUSCLES 

A  thorough  knowledge  of  the  soft  parts,  which  fill  in  the  outlet 
of  the  pelvis  and  constitute  the  pelvic  floor,  is  of  great  importance 
to  Ihe  obstetrician,  since  they  not  only  form  the  inferior  wall  of 
the  whole  abdominal  cavity  and  support  the  downward  pressure 
of  the  viscera,*  but  they  also  form  the  true  boundaries  of  the 
lower  portion  of  the  canal  through  which  the  child  must  pass  in 
parturition,  and  by  their  presence  diminish  the  diameter  of  that 
canal.  During  parturition,  these  soft  parts  are  greatly  compressed 
and  undergo  a  change  of  position,  which  is  the  direct  result  of  the 
anatomical  disposition  of  the  various  structures.  All  the  soft  parts 
of  the  outlet  collectively  form  the  pelvic  floor,  but  anatomically  it 
is  customary  to  divide  them  into  two  parts : — 

I.  The  structures  which  lie  superficial  and  inferior  to  the  pelvic 
diaphragm  and  constitute  the  perinaerm. 

II.  The  pelvic  diaphragm,  a  muscular  partition  which  stretches 
across  the  pelvic  cavity,  and  divides  it  into  an  upper  abdominal 
and  a  lower  perinaeal  part. 

For  purposes  of  description  it  is  convenient  to  follow  this  plan. 

I.  The  Perinaeum. — The  perinaeum  is  the  lozenge-shaped  area, 
bounded  by  the  structures  which  surround  the  outlet  of  the  pelvis, 
and  is  divided  into  a  posterior  rectal,  and  an  anterior  urogenital, 
triangle,  by  a  line  drawn  transversely  between  the  tubera  ischii  and 
just  in  front  of  the  anus.  This  method  of  division  is  convenient, 
inasmuch  as  it  includes  the  whole  of  the  vagina  within  one 
triangle,  but  it  does  not  correspond  to  a  division  which,  on  physio- 
logical grounds,  is  made  of  the  whole  pelvic  floor,  into  an  anterior 
and  a  posterior  segment.  According  to  this  latter  division,  all  the 
structures  contained  within  the  urogenital  triangle  lying  posterior 
to  the  anterior  vaginal  wall,  together  with  the  structures  of  the 
rectal  triangle,  comprise  the  posterior  segment,  while  the  anterior 
vaginal  wall  and  the  structures  in  front  of  it  constitute  the  anterior 
segment. 

The  rectal  triangle  contains  the  anal  orifice  and  the  lower  portion 
of  the  rectum,  the  latter  being  bounded  on  each  side  by  a  fossa, 
the  ischio-rectal  fossa,  filled  with  a  large  pad  of  fat.  The  anal 
orifice  is,  in  the  erect  position,  directed  almost  horizontally  back- 
wards, and  is  separated  from  the  tip  of  the  coccyx  by  the  ano- 
coccygeal body,  a  mass  of  dense  connective  tissue  into  which 
some  fibres  of  the  levator  ani  muscle  pass  from  above.  In  front, 
the  anus  is  separated  from  the  vaginal  orifice  by  the  wedge- 
shaped  perinaeal  body.  Into  this  body  (the  obstetrical  perinaeum) 
the  anterior  rectal  and  the  posterior  vaginal  walls  extend  from 

*  Owing  to  the  contractile  power  of  most  of  the  abdominal  parietes,  the 
pressure  of  the  viscera  is  conveyed  to  the  abdominal  walls  in  a  manner  analo- 
gous to  what  would  occur  if  the  abdomen  were  a  closed  vessel  filled  with  fluid 
— i.e.,  in  the  form  of  fluid  pressure. 


6o 


OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 


above,  together  with  a  few  fibres  of  the  levator  ani  muscle  which 
pass  inwards  from  both  sides.  Within  it,  tendinous  fibres  of 
several  of  the  superficial  perinaeal  muscles  arise,  the  fibres  being 
blended  together  at  the  place  of  origin  so  as  to  form  a  tendinous 
mass,  which  constitutes  a  fixed  point  from  which  all  the  muscles 
act,  and  which  in  consequence  is  termed  the  central  point  of 
the  perinaeum.  The  fat  within  the  ischio-rectal  fossa  is  capable  of 
altering  its  shape  and  position  under  the  influence  of  pressure,  and 
accommodates  itself  to  changes  in  the  state  of  distension  of  the 
rectum  and  of  the  vagina.  The  fossa  itself  is  pyramidal  in  shape, 
and  lies  on  the  inner  side  of  the  body  of  the  ischium.  Its  inner 
boundary  is  formed  by  the  pelvic  diaphragm. 

The   urogenital    triangle    contains   the    urethral    and   vaginal 
openings,  and  is  divided  into  a  superficial  and  a  deep  compart- 


Fig.  41. — Pelvic  Diaphragm  from  Above. 

1,  Ischio-coccygeus  ;   2,  obturato-coccygeus ;   3,  pubo-cocc3'geus  ;   4,5,  linea 

alba.     (Bumm.) 


ment  by  the  triangular  ligament.  This  ligament  fills  up  the 
subpubic  space,  and  is  attached  on  each  side  to  the  rami  of  the 
pubis  and  ischium.  Posteriorly,  it  ends  by  a  free  margin,  which 
is  prolonged  in  the  mesial  plane  into  the  perinaeal  body.  It  is 
perforated  by  the  urethral  and  vaginal  canals,  to  both  of  which  it 
gives  support  as  they  pass  towards  the  surface.  In  the  super- 
ficial compartment  there  lies  on  each  side  of  the  vagina  the  bulb 
of  the  vestibule,  over  which  are  spread  the  fibres  of  the  bulbo- 
cavernosus  muscle.  This  compartment  also  contains  the  crura 
clitoridis,  attached  to  the  sides  of  the  pubic  arch,  and  covered 
by  the  erector  clitoridis  muscles.  A  third  muscle — the  transversus 
perinsei — lies  along  the  base  of  the  triangular  ligament.     It  arises 


THE  PERINJEUM 


61 


from  the  ascending  ramus  of  the  ischium  on  each  side,  and  its 
two  heads  passing  inwards,  unite  to  form  a  tendon  which  is 
blended  with  the  central  point  of  the  perinaeum.  This  muscle  is 
the  first  to  tear  in  ruptures  of  the  perinaeum,  and  the  pull  of  its 
fibres  aids  in  preventing  the  two  sides  of  the  rupture  from  coming 
together. 

The  deep  perinaeal  compartment  is  contained  Letween  the 
triangular  ligament  and  that  portion  of  the  parietal  pelvic  fascia 
which  is  carried  across  the  subpubic  space.  It  contains  a  portion 
of  the  urethra  and  vagina,  together  with  the  compressor  urethrae 
muscle  and  the  pudic  vessels  and  nerves.  Within  this  compart- 
ment also  lie  the  glands  of  Bartholin.  The  compressor  urethrae 
muscle  exerts  a  sphincteric  action   upon  both   the    vagina   and 


Fig.  42. — Pelvic  Diaphragm  from  Below. 

i,  Ischio-coccygeus  ;   2,  obturato-coccygeus ;  3,  pubo-coccygeus ;  4,  perinaeal 
muscles.     (Bumm.) 


urethra.  Arising  from  the  side  of  the  pubic  arch,  it  passes  in- 
wards, and  divides  into  an  upper  (anterior)  and  a  lower  (pos- 
terior) part.  The  upper  portion  passes  in  front  of  the  urethra, 
and  meets  its  fellow  of  the  opposite  side  in  the  middle  line ;  the 
lower  part  turns  backwards  on  the  side  of  the  vagina,  and  blends 
posteriorly  with  its  fellow,  so  as  to  form  an  almost  complete 
muscular  circle  around  the  vagina.  When  the  layer  of  pelvic 
fascia  which  forms  the  deep  boundary  of  the  deep  perinasal  com- 
partment is  removed  the  levator  ani  muscle  is  exposed  both  in 
front,  between  the  urethra  and  the  subpubic  angle,  and  on  each 
side  of  the  vagina. 

We  have  now  passed  rapidly  under  survey  the  structures  which 
lie  below  the  pelvic  diaphragm,  and  have  seen  how  the  levator 
ani  muscle  is  related  to  both  the  posterior  and  anterior  triangles 


62  OBSTETRICAL  ANATOMY— MATERNAL   AND  OVULAR 

of  the  perinseum.  We  may,  therefore,  now  proceed  to  consider 
the  pelvic  diaphragm  itself. 

The  Pelvic  Diaphragm. — On  looking  from  above  into  a  pelvis 
from  which  the  upper  portions  of  the  viscera  have  been  removed 
at  the  level  at  which  they  leave  the  abdominal  portion  of  the 
pelvis  and  pass  into  the  perinasum,  the  floor  will  present  a  funnel- 
shaped  appearance,  and  at  the  apex  of  the  funnel  there  will  be 
seen  in  section  from  before  backwards  the  canals  of  the  urethra, 
the  vagina,  and  the  rectum.  The  floor  or  diaphragm  is  formed  of 
two  muscles  on  each  side — the  levator  ani  and  the  coccygeus — 
which  arise  from  the  anterior  and  lateral  aspect  of  the  pelvic 
walls,  and  pass  downwards  and  inwards  towards  the  mesial 
plane.  Approaching  the  mesial  plane,  the  middle  portion  of  the 
diaphragm  is  prolonged  downwards  on  each  side  of  the  rectum, 
and  to  a  less  extent  upon  the  vagina,  and  thus  gives  rise  to  the 
funnel-shaped  appearance. 

The  levator  ani  muscle  arises  from  the  posterior  part  of  the 
symphysis  pubis,  and  from  a  band  of  fascia  (the  linea  alba), 
which,  lying  upon  the  obturator  internus  muscle  externally, 
extends  from  the  symphysis  to  the  spine  of  the  ischium.  The 
fibres  which  arise  from  the  symphysis  pass  backwards  and  inwards 
from  their  origin,  and  form  the  pubo-coccygeus  muscle  of  Savage.* 
Three  main  sets  of  fibres  may  be  recognised  in  this  muscle:  — 
(i)  An  internal  group,  which  passes  from  the  origin  downwards 
and  inwards  by  the  side  of  the  urethra  and  the  vagina.  A  few 
fibres  of  this  group  turn  inwards  between  the  vagina  and  rectum, 
to  meet  similar  ones  from  the  opposite  side,  and  thus  support  the 
vaginal  wall  posteriorly,  and  are  inserted  below  into  the  perinaeal 
body.  This  portion  of  the  muscle  is  said  to  exert  a  sphincteric 
action  upon  the  vagina.  (2)  A  middle  group,  which  passes  down- 
wards and  inwards  by  the  side  of  the  rectum,  and  blends  below 
with  the  sphincters  of  the  anal  canal.  This  portion  of  the  muscle 
forms  the  internal  boundary  of  the  ischio-rectal  fossa.  (3)  An 
external  group,  which  passes  backwards  and  inwards,  and  is  in- 
serted partly  into  the  side  of  the  lower  portion  of  the  coccyx, 
and  partly  into  a  median  raphe,  which  extends  from  the  tip  of  the 
coccyx  to  the  rectum,  and  in  which  it  blends  with  the  muscle  of 
the  opposite  side.  The  pubo-coccygeus  muscle  as  a  whole  is  of 
a  triangular  shape,  with  its  apex  above  at  its  origin,  and  with  a 
widely  outspread  insertion  which  extends  from  the  urethra  to 
the  coccyx.  The  portion  of  the  levator  ani  muscle  which  has  a 
fascial  origin  (obturato-coccygeus  muscle)  is,  on  the  contrary, 
wide  above  at  its  origin,  and  its  fibres  converge  inferiorly,  to  be 
inserted  into  the  side  of  the  lower  portion  of  the  coccyx. 

The  coccygeus  muscle  (ischio-coccygeus)  is  a  small  triangular 
muscle  lying  on  the  deep  surface  of  the  lesser  sacro-sciatic  liga- 
ment.   It  arises  by  its  apex  from  the  spine  of  the  ischium,  and  by 

*  Savage,  '  Female  Pelvic  Organs,'  third  edition,  p.  2  et  seq. 


THE  PELVIC  MUSCLES  63 

its  base  is  inserted  into  the  side  of  the  lower  part  of  the  sacrum 
and  upper  part  of  the  coccyx.  It  completes  the  pelvic  diaphragm 
posteriorly. 

The  floor  of  the  pelvis,  constituted  as  above  described,  is  divided 
into  a  pubic  and  a  sacral  segment  by  the  transverse  slit  formed  by 
the  vagina.  The  pubic  segment  is  triangular  in  shape.  It  in- 
cludes the  anterior  vaginal  wall  and  that  part  of  the  floor  which 
lies  anterior  to  it.  The  sacral  segment  comprises  the  remainder 
of  the  floor,  including  the  posterior  vaginal  wall,  and  is  roughly 
quadrilateral  in  shape. 

This  division  into  two  parts  is  justified  by  the  different  be- 
haviour of  the  two  segments  during  parturition.  When  the 
muscular  wall  of  the  uterus  commences  to  contract  and  retract, 
it  exerts  a  direct  pull  upon  the  lower  uterine  segment  and  vaginal 
canal,  while  at  the  same  time  the  advancing  foetus  exerts  a  down- 
ward pressure  upon  the  same  segment.  The  result  is  that,  during 
the  first  and  second  stages  of  labour,  the  vaginal  walls  glide  apart 
from  one  another ;  the  anterior,  together  with  the  pubic  segment 
of  the  pelvic  floor,  is  pulled  upwards  and  forwards,  and  the  pos- 
terior, along  with  the  sacral  segment,  is  pushed  downwards  and 
backwards,  so  that  the  transverse  slit  made  by  the  vagina  in  the 
pelvic  floor  becomes  converted  into  an  elongated  oval  aperture, 
the  long  axis  of  which  is  antero-posterior.  As  labour  proceeds, 
the  pubic  segment  becomes  more  and  more  drawn  upwards  and 
pressed  forwards  against  the  pubes,  and  consequently  appears 
shortened.  The  posterior  segment,  on  the  contrary,  is  lengthened. 
Its  upper  part,  along  with  the  lower -portion  of  the  rectum,  is 
pressed  almost  directly  backwards,  and  its  lower  part  becomes 
flattened  out  before  the  advancing  head.  The  anterior  boundary 
of  the  complete  segment  is  formed  by  the  greatly  stretched  trans- 
versa perinaei  muscle  and  by  that  part  of  the  triangular  ligament 
which  lies  posterior  to  the  vaginal  orifice.* 

The  Muscles  and  Cellular  Tissue  within  the  Pelvis. — An  account 
of  the  pelvis  from  the  obstetrical  point  of  view  would  not  be 
complete  without  a  brief  reference  to  the  muscles  and  cellular 
tissue  contained  within  it,  since  the  former  modify  to  a  slight 
extent  the  lengths  of  the  pelvic  diameters,  and  the  latter  acts  as 
supporting  tissue  for  the  structures  contained  within  the  cavity. 

The  Iliacns  Muscle. — This  arises  from  that  part  of  the  iliac  bone 
which  bounds  the  false  pelvis.  Its  fibres  gradually  converge, 
and  leave  the  pelvis  by  passing  under  Poupart's  ligament.  They 
are  inserted  into  the  outer  margin  of  the  tendon  of  the  psoas 
muscle. 

The  Psoas  Muscle. — This  arises  from  the  bodies  and  transverse 
processes  of  the  lumbar  vertebrae,  and  passes  downwards  on  the 
inner  side  of  the  iliacus  to  its  insertion  into  the  femur.  As  it 
skirts  the  brim  of  the  pelvis  it  slightly  overlaps  the  ilio-pectineal 

*  For  further  information,  see  under  Mechanical  Phenomena  of  Labour. 


64  OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 

line,  and,  taken  together,  the  two  psoas  muscles  diminish  the 
transverse  diameter  of  the  inlet  by  about  half  an  inch. 

The  Pyriformis  Muscle. — This  lies  in  relation  to  the  posterior 
pelvic  wall.  It  arises  from  the  front  of  the  middle  three  pieces  of 
the  sacrum  external  to  the  anterior  sacral  foramina,  and  leaves 
the  pelvis  through  the  great  sacro-sciatic  foramen.  Together 
with  the  sacral  nerves  and  a  number  of  arteries,  it  fills  in  the  gap 
left  by  that  foramen  in  the  posterior  part  of  the  pelvis. 

The  Obturator  Intemus. — This  is  a  fan-shaped  muscle  which  lies 
in  relation  to  the  anterior  and  lateral  pelvic  wall,  covering  over 
the  thyroid  foramen.  It  arises  from  the  body  of  the  ischium,  the 
margins  of  the  thyroid  foramen,  and  from  the  thyroid  membrane, 
and  its  tendon  leaves  the  pelvis  through  the  small  sacro-sciatic 
foramen.  Its  upper  part  lies  above  the  level  of  the  origin  of  the 
levator  ani  muscle,  and  is  consequently  in  relation  to  the  true 
pelvis ;  its  lower  part  lying  below  the  levator  ani,  bounds  the 
ischio-rectal  fossa  externally. 

The  Pelvic  Cellular  Tissue. — All  the  structures  within  the  pelvis 
are  closely  bound  together  by  the  pelvic  cellular  tissue,  which  is 
composed  of  ordinary  fibrous  tissue  largely  intermixed  with  elastic 
fibres  and  involuntary  muscular  tissue.  Its  arrangement  is  very 
complex,  but  it  may  be  regarded  as  being  arranged  in  two  distinct 
bands,  which  help  to  suspend  the  uterus  within  the  pelvic  cavity, 
acting  upon  it  as  so  many  lines  of  tension.*  These  two  bands  are 
called  from  their  position  the  pubo-sacral  and  the  utero-iliac.  The 
former  band  runs  in  an  antero-posterior  direction  and  comprises 
the  tissue  contained  within  the  utero-sacral  ligaments,  that  which 
binds  the  vagina  and  uterus  to  the  bladder  and  urethra,  and  also 
the  tissue  which  lies  between  the  bladder  and  the  pubis.  The 
latter  band  runs  transversely,  accompanying  the  uterine  vessels 
in  the  broad  ligament,  and  passing  from  either  side  of  the  uterus 
to  the  lateral  pelvic  wall. 


THE  MAMMARY  GLANDS 

The  mammary  glands,  and  the  purpose  they  serve  of  feeding 
the  young  in  the  early  days  of  extra-uterine  life,  are  a  distin- 
guishing characteristic  of  the  class  mammalia.  Though  epiblastic 
in  origin,  these  glands  must  be  regarded  as  an  essential  part  of  the 
female  reproductive  organs.  Their  intimate  physiological  connec- 
tion with  the  uterus  and  ovaries  is  shown  by  the  changes  which 
they  undergo  during  pregnancy  and  menstruation,  and  by  altera- 
tions which  sometimes  occur  in  them  in  association  with  patho- 
logical conditions  in  these  organs. 

When  fully  developed  in  the  human  female,  they  form  hemi- 
spherical elevations  placed  on  each  side  of  the  front  of  the  thorax, 

*  Savage,  '  Female  Pelvic  Organs,'  third  edition. 


THE  MAMMARY  GLANDS 


65 


and  extending  in  a  vertical  direction  from  the  second  rib  above 
to  the  seventh  costal  arch  below  ;  in  a  transverse  direction  they 
extend  from  the  lateral  margin  of  the  sternum  to  the  mid-axillary 
line,  so  that  the  lower  margin  of  the  pectoralis  major  muscle 
divides  each  gland  into  an  almost  equal  upper  and  inner  pectoral 
part,  and  a  lower  and  outer  axillary  part. 

Each  gland  lies  embedded  in  the  subcutaneous  tissue,  which 
not  only  covers  it  superficially  and  separates  it  from  the  subjacent 
muscles,   but  also  extends  into  the  intervals  between  the  lobes 


Fig.   43. — Mammary  Gland  during  Lactation. 
a.  Fat ;  b,  lobule  unravelled  ;  c,  lobule  ;  d,  loculi  in  connective  tissue  ; 
e,  ampulla ;  /,  duct.     (Luschka.) 


and  lobules,  and  thus  gives  it  its  smooth  and  rounded  appearance. 
Processes  of  the  gland,  however,  often  project  for  a  considerable 
distance  from  the  main   mass  into  the  surrounding  fibrous  and 

cldlDOSG  tissue 

On  the  summit  of  each  gland  is  placed  a  small  cylindrical 
elevation— the  nipple  or  mamilla— and  this  is  situated  at  about 
the  level  of  the  fourth  intercostal  space  and  four  inches  from  the 
middle  line.  The  colour  of  the  skin  covering  the  nipple  is,  as 
a   rule,    rose-pink  in   nulliparae,    but   varies  somewhat  with   the 

5 


66 


OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 


complexion  of  the  individual,  being  slightly  darker  in  brunettes 
than  in  blondes.  Surrounding  the  nipple  for  a  distance  of  about 
half  an  inch  is  a  circle  of  skin,  the  areola,  which  is  coloured  of  the 
same  hue  as  the  nipple.  Immediately  deep  to  the  areola,  lie 
the  dilated  ampullae  of  the  mammary  ducts,  without  any  fatty 
tissue  intervening.  On  its  surface  several  small  prominences  or 
tubercles  are  visible.  Some  of  these  are  formed  by  accumulations 
of  large  sebaceous  glands — Montgomery's  tubercles,  the  secretion 
of  which  helps  to  preserve  the  normal  softness  and  elasticity  of 
the  integument ;  others  are  formed  by  the  presence  of  small 
accessory  milk  glands  ;  and  others,  again,  mark  the  opening  of 
some  of  the  ducts  of  the  mammary  gland  itself. 

The  glandular  substance  of  the  breast  is  encased  in  a  sheath 
of  fibrous  tissue,  which  separates  it  from  the  surrounding  fat  and 
sends  septa  into  the  gland,  so  dividing  it  up  into  lobes  and  lobules. 
The  lobes  are  from  fifteen  to  twenty  in  number,  and  each  possesses 


^mh. 


-?-  -.  ',-§>_ 


Wmk 


w&: 


tS  ■  - 


Fig.  44. — Lactating  Breast. 
Microscopical  section  showing  the  secreting  acini.     (W.  Williams.) 


a  separate  duct.  All  the  ducts  converge  towards  the  nipple  and 
they  become  dilated  into  ampullar  spaces  beneath  the  areola;  then 
narrowing  again,  each  duct  passes  to  the  summit  of  the  nipple, 
where  it  communicates  with  the  exterior  by  a  very  small  opening. 
The  wall  of  the  duct  is  formed  by  connective  tissue  and  elastic 
fibres  arranged  circularly  and  longitudinally,  and  is  lined  by 
a  layer  of  low  columnar  epithelium.  When  the  duct  is  traced  to 
the  surface,  it  is  found  that  the  epidermis  extends  into  it  for  a 
short  distance  and  replaces  the  columnar  layer  of  cells.  Traced 
in  the  opposite  direction,  each  duct  is  found  to  divide  and  sub- 
divide, till  finally  its  terminal  ramifications,  lined  by  almost  flat 
epithelium,  open  into  acinous  spaces  which  constitute  the  secreting 
substance  of  the  mamma.  In  the  virgin,  the  acini  are  supported 
by  a  basement  membrane  of  connective  tissue,  and  are  lined  by 
a  layer  of  high  columnar  cells,  which  completely  occlude  the  lumen, 
and  which  are  composed  of  granular  protoplasm.     During  preg- 


THE  MAMMARY  GLANDS 


67 


nancy,  the  acini  become  much  enlarged,  and  at  the  commencement 
of  lactation  are  filled  with  a  clear  secretion,  which  by  its  pressure 
distends  them  and  causes  the  lining  cells  to  assume  a  flatter  ap- 
pearance.    The  inner  margins  of  the  cells  at  this  time  are  ragged 


£g  O  OO  _o  „  „  re,  0_  On  <£°  ° 


^3  O^O^-.    Q^^'ioO    T^A^' 


&*$$#  ^°o%£  j;«^v  *'&* 


fe>*rv£*# 


Fig.  45. — Human  Milk.     (W.  Williams.) 

and  contain  numerous  fat  globules,  which  displace  the  nucleus 
and  protoplasm  outwards.  When  secretion  is  established,  these 
fat  globules  escape  from  the  cell  into  the  lumen  and  form  the 


Fig.  46. — Human  Colostrum.     (W.  Williams.) 


characteristic  milk  globules.  In  addition  to  these  structures, 
during  the  first  few  days  of  lactation  large  numbers  of  cells 
resembling  white  blood  corpuscles  and  containing  fat  droplets 
are  found  within  the  acini.     These  are  the  so-called  colostrum 

5—2 


68         OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 

corpuscles,  and  are  probably  migrated  leucocytes  engorged  with 
the  fat  secreted  by  the  true  glandular  cells. 

The  mamma  is  supplied  with  blood  by  twigs  from  the  internal 
mammary  artery  and  by  a  large  branch  (the  external  mammary) 
of  the  long  thoracic  artery.  The  latter  winds  round  the  lower 
border  of  the  pectoralis  major  muscle  to  reach  the  breast.  It 
also  receives  twigs  from  the  second,  third,  and  fourth  intercostal 
arteries.  The  veins  in  every  respect  correspond  to  the  arteries. 
The  nipple  and  areola  are  abundantly  supplied  with  blood,  a 
venous  circle  being  formed  around  the  base  of  the  nipple,  and 
at  times  a  sort  of  semi-erection  or  venous  turgescence  of  these 
parts  can  be  produced  by  the  contraction  of  involuntary  muscular 
fibres  which  lie  in  the  neighbourhood  of  the  ampullae.  These 
fibres  not  only  help  to  expel  the  contents  of  the  ampullae  by 
their  contraction,  but  also  retard  the  return  of  venous  blood  by 
compressing  the  veins. 

The  lymphatic  vessels  are  arranged  in  several  groups  within 
the  gland,  all  of  them,  however,  freely  anastomosing  with  one 
another.  The  efferent  trunks  pour  their  contents  into  the  sternal 
and  axillary  groups  of  lymphatic  glands. 


CHAPTER  III 
THE  OVUM 

The  Early  Ovum  :  Extrusion  of  Polar  Bodies ;  Fertilisation  ;  Segmentation  ; 
Blastodermic  Vesicle;  Formation  of  Embryo;  Epiblast,  Mesoblast,  and 
Hypoblast ;  Formation  of  Amnion  ;  Early  Nutrition  of  Foetus  ;  Formation 
of  Allan tois — The  Deciduae — The  Placenta — The  Umbilical  Cord — The 
Liquor  Amnii. 

The  following  short  account  of  the  early  development  of  the 
human  ovum  is  not  intended  to  be  in  any  way  complete,  but  will 
principally  be  concerned  in  showing  the  manner  in  which  the 
foetal  membranes  are  developed,  and  in  which  the  nutrition  and 
growth  of  the  foetus  is  brought  about  at  different  stages  of  its 
existence.  Many  questions  dealing  with  the  exact  mode  of 
formation  of  such  foetal  structures  as  the  amnion  and  allantois 
are  still  unsolved  owing  to  the  difficulty  of  obtaining  for  examina- 
tion human  ova  of  a  sufficiently  early  age.  Of  these  the  greater 
number,  however,  possess  a  purely  morphological  interest,  and 
will  not  be  discussed  here,  except  in  so  far  as  they  are  of  practical 
importance  to  the  student  of  midwifery. 

THE  EARLY  OVUM 

The  human  ovum  prior  to  fertilisation  is  a  small  spherical  cell 
with  a  diameter  of  about  o*2  millimetre,  and  when  first  extruded 
from  the  Graafian  follicle  is  surrounded  by  one  or  more  layers  of 
altered  epithelial  cells  derived  from  the  discus  proligerus.  The 
ovum  itself  possesses  externally  a  limiting  membrane,  which  from 
its  clear  appearance  on  section  is  known  as  the  zona  pellucida. 
Within  this  is  contained  the  proper  substance  of  the  cell,  the  yelk 
or  vitellus.  The  zona  pellucida  is  derived  from  the  ovum  itself, 
but  is  non-adherent  to  the  yelk,  and  in  some  stages  of  develop- 
ment can  be  observed  to  be  separated  from  the  latter  by  a  peri- 
vitelline  space.  When  examined  under  a  high  power  of  the 
microscope,  a  number  of  radiating  striae  may  be  seen  traversing 
it,  which  are  supposed  to  indicate  the  presence  of  minute  cana- 
liculi,  and  this  appearance  has  gained  for  it  the  alternative  name 

69 


70  OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 

of  zona  radiata.  The  vitellus  is  a  yellowish  semi-fluid  substance 
composed  of  two  different  materials,  the  protoplasm  proper  and 
the  nutritive  material  or  deutoplasm.  The  protoplasm,  which  con- 
stitutes its  essential  structure,  forms  a  fine  network  within  the  cell, 
in  the  meshes  of  which  are  scattered  numerous  almost  opaque  fatty 
and  albuminous  particles.  These  latter  provide  a  store  of  nutri- 
ment for  the  ovum  in  its  earliest  stage  of  existence,  and  to  them 
collectively  the  term  '  deutoplasm  '  is  applied.  They  are  small  in 
amount  compared  with  the  deutoplasm  in  the  ova  of  many  other 
animals,  and  are  almost  equally  distributed  throughout  the 
vitellus.  Within  the  latter,  and  usually  eccentrically  placed 
there  is  found  a  large  nucleus  surrounded  by  a  delicate  limiting 
membrane.  The  nucleus,  like  that  of  other  cells,  is  composed  of 
a  clear  nuclear  fluid,  within  which  there  is  found  a  delicate 
reticulum  of  chromatin.     The  latter  is  especially  accumulated  at 


Fig.  47. — Ovum  of  Rabbit. 

a,  Portion  of  discus  proligerus  ;  b,  nucleus  containing  nucleolus;  c,  yelk 
containing  deutoplasm  ;  d,  zona  pellucida.     (Waldeyer.) 

one  place,  where  it  forms  the  nucleolus  or  germinal  spot.     Occa- 
sionally more  than  one  nucleolus  is  present. 

After  the  ovum  has  attained  maturity,  either  before  or  imme- 
diately after  its  expulsion  from  the  Graafian  follicle,  certain  im- 
portant changes  take  place  in  it,  without  the  occurrence  of  which 
fertilisation  can  probably  not  take  place.  These  changes  consist 
in  the  extrusion  of  a  portion  of  the  nucleus  and  its  contained 
chromatin  out  of  the  cell,  and  they  commence  by  a  contraction  of 
the  vitellus,  with  the  result  that  the  latter  separates  from  the 
zona  radiata,  and  leaves  a  distinct  perivitelline  space  containing 
a  clear  fluid.  At  the  same  time,  the  margins  of  the  nucleus 
become  obscure,  and  the  latter  migrates  towards  the  periphery 
of  the  cell,  where  it  rapidly  undergoes  the  usual  changes  prior  to 


FERTILISATION 


7i 


cell  division  (karyokinesis)  and  divides  into  two  parts.  One  of 
these  parts  is  expelled  into  the  perivitelline  space,  while  the 
other  part  returns  into  the  cell  and  again  undergoes  karyo- 
kinetic  changes,  with  the  result  that  a  half  is  again  extruded  ;  the 
remainder,  which  is  now  termed  the  female  pro-nucleus,  and 
represents  one-quarter  of  the  original  germinal  vesicle,  gradually 
returns  towards  the  centre  of  the  vitellus,  where  it  awaits  the 
spermatozoon.  The  two  parts  of  the  nucleus  which  have  been 
expelled  are  known  as  the  polar  globules,  owing  to  the  fact  that 
in  those  ova  in  which  the  deutoplasm  is  accumulated  at  one  pole 


Fig.  48. — Ovum  in  Graafian  Follicle. 

a,  Epithelium  on  ovary  ;  b,  tunica  albuginea  ;  c,  stroma  of  ovary  ;  d,  immature 
ovum;  e,  theca  of  Graafian  follicle;  /,  liquor  folliculi;  g,  ovum.     (Piersol.) 


(telolecithal  ova)  extrusion  always  takes  place  at  the  opposite  or 
formative  pole.  They  remain  visible  during  the  early  stages  of 
segmentation,  but  their  ultimate  fate  and  their  significance  is 
unknown.  It  is  possible  that  by  this  removal  of  certain  con- 
stituents of  the  female  nucleus  a  more  equal  transmission  of 
characteristics  from  both  parents  is  assured. 

Fertilisation. — If  impregnation  occurs,  numerous  spermatozoa 
cluster  around  the  germ-cell  external  to  the  zona  pellucida,  either 
during  the  process  of  expulsion  of  the  polar  globules  or  shortly 
afterwards.  One  of  these,  probably  the  first  to  approach  the 
ovum,  strikes  the  surface  of  the  membrane  with  its  head,  and  at 
the  point  of  contact  a  small  elevation  forms.  Through  this  the 
spermatozoon  gradually  bores  its  way  into  the  cell.     In  many 


72 


OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 


invertebrates  a  definite  channel,  the  micropyle,  exists  in  the 
limiting  membrane,  and  through  this  the  spermatozoon  reaches  the 
vitellus,  but  none  has  been  demonstrated  in  the  ova  of  mammalia. 
When  the  sperm-cell  has  completely  penetrated  into  the  vitellus, 
its  tail  ceases  to  vibrate  and  disappears,  while  the  head  and 
middle  portion,  which  are  both  nuclear  in  origin,  form  a  small 
spheroidal  corpuscle,  the  male  pro-nucleus.      The  latter  moves 


Fig.  49. — Diagrams  to  show  Fertilisation  of  the  Ovum. 

a,  Zona  pellucida  ;   b,  perivitelline  space  ;  c,  polar  globules. 

In  A,  the  spermatozoon  has  approached  ovum  ;  in  B,  the  radial  disposition  of 
the  yelk  is  seen  ;  and  in  C,  the  male  pro-nucleus  is  approaching  the  female 
pro-nucleus.     (Selenka. ) 


towards  the  centre  of  the  cell  in  the  direction  of  the  female  pro- 
nucleus, exerting  as  it  does  so  a  peculiar  influence  upon  the 
surrounding  protoplasm,  which  becomes  arranged  in  radiating 
lines  around  it.  The  female  pro-nucleus  also  moves,  though  less 
actively,  to  meet  it,  and  finally  they  come  into  close  contact  with 
one  another,  and  become  surrounded  by  a  common  radiation. 
An  interchange  of  chromatic  particles  now  takes  place,  though  no 
actual  fusion  occurs,  and  it  is  probable  that  in  each  subsequent 


THE  BLASTODERMIC   VESICLE 


73 


division  of  the  combined  nucleus  a  portion  of  both  the  male  and 
female  element  passes  into  each  cell. 

Segmentation. — A  short  period  of  rest  follows  upon  the  fusion 
of  the  male  and  female  pro-nuclei,  and  then  the  process  of  seg- 
mentation commences.  The  ovum  first  divides  into  two  cells, 
and  then  each  of  these  again  rapidly  divides  into  two  more.  This 
process  repeatedly  occurs  until  a  cluster  of  cells  is  formed  con- 
tained within  the  vitelline  membrane,  and  this  from  its  appearance 


Fig. 


50. — Diagrams  showing  Segmentation  of  a   Mammalian  Ovum, 
and  the  Formation  of  the  Blastodermic  Vesicle. 


Nos.  1-4  represent  the  early  stages  in  division  of  the  ovum  ;  No.  5 
represents  the  morula  stage ;  in  No.  6  the  effusion  of  fluid  and  com- 
mencement of  formation  of  the  blastodermic  vesicle  is  shown  ;  and  in 
Nos.  7  and  8  the  gradual  spreading  out  of  the  inner  layer  of  cells  is 
represented.     (Allen  Thomson,  after  van  Beneden.) 


is  called  the  mulberry  mass,  or  morula.  The  outer  cells  of  this 
mass  are  seen  to  be  smaller  and  less  granular  than  the  inner  cells, 
which  are  larger  and  darker  in  appearance.  The  former  also  after 
a  time  undergo  more  rapid  proliferation,  so  that  ultimately  they 
form  a  complete  investing  membrane  around  the  others. 

The  Blastodermic  Vesicle. — A  cleavage  cavity  is  now  formed 
within  the  centre  of  the  morula  by  the  effusion  of  fluid  and  the 
separation  of  the  cells',  and,  gradually  increasing  in  size,  the 
morula  is  converted  into  a  large  thin-walled  sac  bounded  by  the 
thinned-out  zona  pellucida,  and  by  the  layer  of  outer  clear  cells 
which  have  also  become  greatly  thinned  as  a  result  of  the 
pressure  to  which  they  have  been  subjected.  Attached  at  one 
point  to  the  inner  surface  of  this  limiting  membrane,  is  found  the 
group  of  large  cells  which  previously  occupied  the  entire  centre  of 
the  morula.     This  stage  of  the  ovum  is  known  as  the  blastula 


74 


OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 


stage,  and  it  is  in  turn  converted  into  the  bi-laminar  blastodermic 
vesicle  by  the  spreading  out  of  the  cluster  of  dark  cells  upon  the 
inner  surface  of  the  external  layer.  As  these  cells  proliferate  and 
extend  outwards  on  each  side  they  become  differentiated  into  two 
distinct  layers — an  outer,  composed  of  primitive  epithelioid  cells, 
the  primitive  ectoderm  or  epiblast,  and  an  inner  layer  of  flattened 


Fig.    51. 


Embryonic   Area,    showing    Primitive    Streak    and    Groove 
(Quain.) 


cells,  the  primitive  entoderm  or  hypoblast.  The  original  layer  of 
clear  cells,  which  at  first  lay  in  contact  with  the  zona  pellucida, 
entirely  disappears. 

Formation  of  Embryo. — Long  before  the  blastoderm  is  com- 
pletely   formed    by   the    extension    round    it    of    the    primitive 


Fig.  52. — Embryonic  Area  from  Rabbit's  Ovum. 

rj.  Neural  groove  ;  bl.  v.,  blastodermic  vesicle  ;  pr,  primitive  groove  ; 
ag,  embryonic  area.     (Kolliker.) 


epiblast  and  hypoblast,  changes  occur  at  the  place  where  the 
cluster  of  dark  cells  was  attached,  and  lead  to  the  differentiation 
of  the  embryo  from  the  remainder  of  the  ovum.  Over  a  some- 
what oval  area  in  this  situation,  the  germ  layers,  more  especially 
the  ectoderm,  become  thickened,  and  the  cells  of  which  they  are 
composed  become  more  tightly  packed  together,  so  that  this  area 


THE  FORMATION  OF  THE  EMBRYO 


75 


becomes  more  opaque  than  surrounding  parts.  To  this  is  given 
the  name  of  embryonic  area  in  consequence  of  the  part  which  it 
plays  in  the  further  development  of  the  embryo.  Over  the 
posterior  part  of  this  area  a  dark  spot  of  crescentic  form  appears, 
the  concavity  of  which   is  directed  forwards.      This  marks  the 


Fig.  53. — Sections  through  Embryonic  Area,  showing  the  Formation 
of  the  Mesoblast  on  Each  Side  of  the  Primitive  Groove. 

g,  Primitive  groove  ;  c,  epiblast ;  d,  mesoblast;  e,  hypoblast.     (Heape.) 

place  at  which  the  two  layers  of  cells  have  become  continuous 
with  one  another,  and,  passing  forward  from  it  along  the  em- 
bryonic area,  there  is  very  shortly  seen  an  opaque  line,  along 
which  a  similar  fusion  of  cells  has  occurred.  This  line  is  known 
as  the  primitive  streak,  and  it  is  grooved  along  its  upper  surface, 


Fig.  54. — Section  through  Medullary  Groove  of  an  Early  Embryo. 
c,  Epiblast;  d,  mesoblast;  e,  hypoblast;  b,  neural  groove.     (Quain.) 


by  the  primitive  groove.  If  sections  are  now  made  through  the 
embryonic  area  across  the  line  of  the  primitive  streak,  it  will  be 
seen  that  on  each  side  of  the  latter  a  third  layer  of  cells  has 
made  its  appearance  between  the  two  previously  existing  layers. 
The  exact  origin  of  this  middle  stratum,  which  is  called  the 
mesoblast,  is  still  a  matter  of  considerable  doubt,  but  it  is  most 


76         OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 

probable  that  it  is  derived  by  proliferation  of  the  cells  of  both  the 
epiblast  and  hypoblast  along  their  line  of  union,  and  that  origin- 
ating in  this  way  they  spread  out  on  each  side  and  also  forwards, 
separating  the  two  original  layers,  and  thus  giving  a  tri-laminar 
structure  to  the  previously  bi-laminar  blastoderm. 

Immediately  in  front  of  the  primitive  streak,  and  within  the 
limits  of  the  embryonic  area,  the  first  rudiment  of  the  embryo 
makes  its  appearance  in  the  form  of  a  groove,  which,  since  it 
becomes  later  developed  into  the  nervous  system,  is  called  the 
neural  groove.  This  groove,  which  must  be  carefully  distin- 
guished from  the  primitive  groove,  is  formed  during  the  growth 
of  the  mesoblast  by  the  proliferation  of  the  cells  of  the  epiblast. 
The  proliferation  causes  the  epiblast  to  become  raised  up  into 
two  longitudinally  running  folds,  which  enclose  between  them  the 
groove,  and  are  termed  the  neural  or  medullary  folds.  The  groove 
is  wide  posteriorly  where  it  embraces  the  anterior  extremity  of 
the  primitive  streak,  but  narrows  in  front,  where  the  two  folds 
which  bound  it  laterally  become  united  with  one  another  to  form 
its  anterior  limit.  Meanwhile,  the  mesoblast  has  been  extending 
forwards,  and,  as  soon  as  the  medullary  folds  are  formed,  it  in- 
sinuates itself  into  them  on  each  side  between  the  epiblast  and 
the  hypoblast,  so  as  to  form  ridges  of  mesoblast  triangular  on 
cross-section,  lying  on  each  side  of  the  neural  groove,  and 
separated  from  one  another  in  the  middle  line  by  the  union  of 
epiblast  and  hypoblast  at  the  bottom  of  this  groove.  These 
ridges  are  known  as  the  par-axial  mesoblast,  in  contradistinction 
to  the  remainder  of  that  layer,  which  extends  as  a  flattened  plate 
on  each  side,  and  is  termed  the  lateral  mesoblast. 

The  par-axial  mesoblast  soon  becomes  divided  up  into  a  series 
of  segments  by  a  process  of  thinning,  which  occurs  at  regular 
intervals  across  it,  forming  the  protovertebral  or  mesoblastic 
somites,  which  in  their  further  development  form  the  vertebral 
column,  the  muscles  of  the  trunk,  and  those  of  the  extremities. 
The  lateral  mesoblast  undergoes  a  different  change.  By  the 
effusion  of  fluid  between  the  cells  of  which  it  is  composed,  it 
becomes  separated  into  two  layers,  of  which  the  outer,  known  as 
the  somato-pleural  layer,  adheres  to  the  epiblast,  and  forms  the 
connective-tissue  structures  of  the  body  wall.  The  inner,  known 
as  the  splanchno-pleural  layer,  adheres  to  the  hypoblast,  and 
forms  the  muscular  and  connective  tissue  of  the  abdominal  and 
thoracic  viscera.  The  space  which  separates  the  two  layers  is 
the  first  appearance  of  the  coelom  or  body  cavity,  which  sub- 
sequently becomes  divided  into  various  compartments,  and  forms 
the  large  serous  cavities. 

Meanwhile,  by  a  gradual  infolding  of  the  ridges  which  bound 
the  neural  groove,  the  latter  has  been  converted  into  a  closed  tube 
— the  neural  canal — which  is  at  first  in  contact  with  the  external 
layer  of  epiblast,  but  is  later  separated  from  it  by  the  growth  of 
processes  of  the  par-axial  mesoblast  dorsalwards  between  it  and  the 


THE  FORMATION  OF  THE  EMBYRO 


11 


surface  layer.     The  neural  canal  is  the  rudiment  from  which  the 
whole  of  the   nervous  system,   both    central    and    peripheral,  is 


D 


%sg$p*>*r~«"^gt; 


Fig.   55. — Sections    showing   Stages   in    Conversion    of   Medullary 
Groove  into  Neural  Canal. 

a,  Mesoblast  of  amnion  ;  b,  neural  groove  ;  c,  epiblast ;  d,  mesoblast ; 
e,  hypoblast ;  /,  notochord. 


developed.     It  marks  the  long  axis  of  the  body,  and  immediately 
subjacent  to  it  there  lies  a  longitudinally-running  column,  circular 


Epiblast 


78         OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 

in  transverse  section,  which  is  called  the  notochord,  or  chorda 
dorsalis.  This  has  been  produced  by  a  thickening  of  the  hypo- 
blast, and  becomes  separated  both  from  the  subjacent  hypoblast 
and  from  the  neural  canal  by  the  ingrowth  of  processes  of  the 
mesoblast.     It  is  the  precursor  of  the  vertebral  column. 

Before  going  further,  it  may  be  well  to  enumerate  the  various 
tissues  and  organs  which  are  developed  out  of  the  three  primitive 
layers  of  the  embryo.  For  convenience  they  may  be  arranged  in 
a  tabular  form  : — 

'The  epidermis  and  its  appendages. 

The  nervous  system. 

The  epithelium  of  the  mouth,  nose,  anal  canal,  and  vagina. 

The  epithelium  of  the  sebaceous  glands,  sweat  glands,  and  mam- 
mary glands. 
,  The  epithelium  of  the  eye  and  ear. 

[The  supporting  and  connective  tissues  of  the  body. 
The  vascular  and  lymphatic  system. 
M      ,  ,         J  The  urinary  and  generative  organs,  with  the  exception  of  the 
1     sod  as     1  epithelium  lining  the  bladder  and  urethra  and  the  germinal 

cells. 
The  spleen. 

/The  epithelium  of  the  alimentary  canal  and  of  the  glands  whose 
ducts  open  into  it. 
„        ,  ,         I  The  epithelium  of  the  thyroid  and  thymus  glands, 
iiypootast  -j  The  epithelium  of  the  biadder  and  urethra. 

The  cells  of  the  Graafian  follicles  and  seminiferous  tubules. 
\The  epithelium  of  the  air-passages. 

Formation  of  Amnion. — The  embryo  represented  by  the  neural 
canal,  the  notochord  and  the  mesoblastic  somites,  has  up  to  this 
been  lying  on  the  same  level  as  the  general  surface  of  the  blasto- 
dermic vesicle,  but  it  soon  becomes  marked  off  from  the  latter  by 
the  development  of  limiting  furrows  around  it.  These  furrows  are 
produced  by  a  dipping  inwards  of  the  somatopleure  all  round, 
and  the  various  folds  thus  produced  grow  in  to  meet  one  another 
on  the  under  surface  of  the  embryo.  In  accordance  with  the  fact 
that  the  head  end  of  the  embryo  always  anticipates  in  develop- 
ment the  other  parts,  this  groove  first  makes  its  appearance  in 
front  of  the  neural  canal  (anterior  limiting  sulcus),  and  then,  as 
the  process  of  enfolding  gradually  extends  to  the  sides,  lateral 
limiting  sulci  are  produced,  which  at  a  still  later  period  become 
united  behind  the  tail  end  of  the  embryo  by  their  extension  to 
form  a  posterior  limiting  sulcus.  The  completed  circumferential 
furrow  marks  out  the  elongated  and  somewhat  tubular-shaped 
embryo  from  the  surrounding  blastoderm,  and  as  during  its 
growth  the  latter,  from  its  greater  weight,  sinks  downwards,  the 
part  of  the  somatopleure  which  bounds  the  furrow  externally 
becomes  raised  up  in  the  form  of  a  definite  ridge,  which  appears 
to  be  reflected  upwards  from  the  bottom  of  the  furrow.  As  the 
grooves  deepen  they  present  an  appearance  as  if  the  somatopleure 
was  being  tucked  in  beneath  the  embryo — i.e.,  on  its  ventral 
aspect — and  as  they  approach  one  another  they  cause  a  portion  of 


THE  FORMATION  OF  THE  AMNION 


79 


the  general  cavity  of  the  blastodermic  vesicle  to  be  enclosed  in 
this  position.     As  we  have  already  seen,  the  cavity  of  the  blasto- 


Fig.  56.  —  Diagrammatic  Section 
through  Ovum,  showing  the 
Neural  Canal  and  Noto- 
chord,  and  also  the  division 
of  the  mesoblast  into  its 
Outer  Somato-pleural,  and 
Inner  Splanchno  -  pleural 
Layers. 


Fig.  57. — Diagram  to  show  Com- 
mencement of  Formation  of 
the  Amnion. 

The  somatopleure  is  raised  up  on 
each  side  of  the  embryo  in  the 
form  of  limiting  ridges. 


Fig.     58. — A    Later     Stage    than 
Fig.  57. 

The  limiting  ridges  are  meeting  above 
the  back  of  the  embryo. 


Fig.  59. — Complete   Formation  of 
Amnion  and  Chorion. 

The  amnion  is  the  small  sac  on  the 
dorsal  aspect  of  the  embryo,  and 
the  chorion  is  the  large  outer  sac. 


dermic  vesicle  is  lined  internally  with  hypoblast,  and  the  portion 
of  it  which  is  in  this  way  separated  off  forms  the  primitive 
alimentary  canal.     This  consists  of  an  anterior  fore  gut,  which 


8o         OBSTETRICAL  ANATOMY—MATERNAL  AND  OVULAR 

terminates  blindly  beneath  the  head  end  of  the  embryo,  and  is 
bounded  by  the  anterior  limiting  sulcus ;  of  a  posterior  hind  gut, 
which  also  terminates  blindly  in  the  tail  end  of  the  embryo,  and 
is  bounded  by  the  posterior  limiting  sulcus ;  and  of  a  middle 
portion — the  mid  gut — which  communicates  by  means  of  a  wide 
aperture  with  the  remaining  portion  of  the  blastodermic  vesicle. 
To  this  extra-embryonic  part  of  the  blastodermic  vesicle  the 
name  of  yolk  sac  is  applied.  By  the  gradual  deepening  of  the 
limiting  sulci,  the  foramen,  through  which  the  sac  is  at  first 
continuous  with  the  mid  gut,  becomes  narrower,  and  is  finally 
converted  into  a  narrow  canal — the  vitelline  duct. 

Meanwhile,  the  ridges  of  somatopleure,  formed  by  the  sinking 
in  of  the  embryo  towards  the  blastodermic  cavity,  have  been 
increasing  in  height,  and  have  begun  to  grow  dorsalwards  over 


Fig.  60. — Diagrammatic  Longitudinal  Section  through  Embryo, 
showing  the  Amniotic  Ridges  and  the  Gradual  Closing  in  of  the 
Anterior  and  Posterior  Limiting  Sulci  on  the  Ventral  Aspect  of 
the  Embryo. 


the  embryo.  The  ridge  which  is  in  front  of  the  head  end  of  the 
embryo  is  at  first  most  marked,  and  from  there  grows  back  as  a 
covering  over  its  dorsum,  to  meet  with  the  lateral  and  posterior 
portions  of  the  ridge,  which  grow  over  in  a  similar  manner, 
though  at  a  somewhat  later  date.  The  free  edges  of  the  several 
folds  for  a  time  bound  a  circular  foramen  over  the  centre  of  the 
embryo,  but  finally  meet  with  one  another,  and  having  com- 
pletely fused,  become  divided  into  two  distinct  membranes  by  the 
recession  of  the  outer  from  the  inner  layer.  The  external  mem- 
brane, composed  of  an  outer  layer  of  epiblast  and  an  inner  layer 
of  mesoblast,  is  continuous  with  the  general  somato-pleural  wall 
of  the  blastoderm,  and  is  called  the  chorion.  The  inner  lamina, 
composed  of  an  outer  layer  of  mesoblast  and  an  inner  layer  of 
epiblast,  is  called  the  amnion,  and  surrounds  a  space  over  the 
dorsal  region  of  the  embryo,  called  the  amniotic  cavity.     This 


THE  EARLY  NUTRITION  OF  THE  FOETUS  81 

cavity  is  at  first  small,  in  comparison  with  the  cavity  of  the 
chorion,  in  which  it  is  contained ;  but  as  the  yolk  sac  atrophies, 
the  amniotic  cavity  increases  in  size  by  the  accumulation  of  fluid 
within  it,  and  comes  to  occupy  the  whole  of  the  chorionic  cavity, 
and  the  amniotic  and  chorionic  membranes  come  into  contact 
with  one  another.  This  distension  of  the  amniotic  cavity  is, 
however,  not  completed  till  a  much  later  date.  The  fluid  which 
it  contains  is  called  the  liquor  amnii,  and  will  be  described 
subsequently. 

The  Early  Nutrition  of  the  Foetus. — It  is  in  connection  with  the 
yolk  sac  that  the  first  evidence  of  a  foetal  circulation  is  manifested. 
Prior  to  its  formation,  the  ovum  is  nourished  by  direct  absorption 
from  the  uterine  decidua,  in  which  it  is  embedded,  probably  partly 
through  the  agency  of  structureless  villi,  which  are  formed  upon 
the  zona  pellucida.  In  many  animals  also  the  ovum  during  its 
passage  through  the  Fallopian  tubes  becomes  surrounded  by  an 
albuminous  envelope,  derived  from  the  secretion  of  the  cells  lining 
the  tubes,  and  this  contributes  to  its  nourishment. 

Vitelline  Circulation. — During  the  changes  which  have  resulted 
in  the  formation  of  the  yolk  sac,  a  simple  heart  has  become 
developed  in  the  splanchno-pleural  mesoblast  beneath  the  head 
end  of  the  embryo,  in  the  form  of  two  tubes,  which  meet  with 
one  another  in  the  middle  line,  and  fuse  so  as  to  form  a  single 
canal,  the  long  axis  of  which  is  directed  antero-posteriorly.  From 
the  cephalic  extremity  of  this  tube,  a  single  arterial  trunk  passes 
forwards  for  a  short  distance,  and  bifurcates  in  the  region  of  the 
first  visceral  arch  into  two  branches,  which  pass  backwards  along 
the  side  of  the  fore  gut,  and  on  reaching  the  dorsum  of  the 
embryo  turn  downwards  towards  its  posterior  extremity,  con- 
stituting what  are  termed  the  primitive  aortae.  From  these 
trunks,  lateral  branches  are  given  off  to  the  yolk  sac,  and  anas- 
tomose on  its  surface,  so  as  to  form  a  complete  circle  around  its 
upper  part.  From  this  ring,  or  sinus  terminalis,  as  it  has  been 
called  by  His,  numerous  smaller  twigs  pass  on  to  the  surface  of 
the  sac,  and  break  up  into  capillaries,  from  which  the  blood  is 
again  collected  into  two  large  venous  channels — the  vitelline 
veins.  These  latter  pour  their  blood  into  the  posterior  extremity 
of  the  tubular  heart.  As  soon  as  the  heart  makes  its  appearance 
it  is  seen  to  be  actively  contracting  and  to  be  driving  blood  along 
the  arteries  to  the  yolk  sac.  The  blood  absorbs  nourishment 
from  the  rich  albuminous  fluid  contained  within  the  latter,  and 
conveys  it  back  along  the  veins  to  the  heart.  This  primitive 
circulation  is  a  very  temporary  and  unimportant  provision  in 
mammalia,  and  is  soon  replaced  by  the  secondary,  or  placental, 
circulation. 

Formation  of  the  Allantois. — As  soon  as  the  chorion  is  formed,  villi, 
which  are  at  first  non-vascular,  develop  over  the  greater  part  of 
its  surface  by  the  rapid  proliferation  of  the  epiblastic  cells  which 
form  its  outer  layer  and  which  project  into  little  depressions  of 

6 


82 


OBSTETRICAL  ANATOMY—MATERNAL  AND  OVULAR 


the  uterine  mucous  membrane  lying  between  the  uterine  glands. 
Probably  these  villi  are  able  to  absorb  directly  some  nourishment 
from  the  uterine  lymphatics.  As  soon  as  the  allantois  becomes 
developed,  however,  the  chorion  and  its  villi  become  altered. 
The  allantois  is  primarily  formed  as  a  hypoblastic  diverticulum 
from  the  ventral  surface  of  the  hind  gut  of  the  embryo,  and  pro- 
jects outwards  into  the  space  of  the  chorionic  cavity,  which  is 
unoccupied  by  the  amnion  and  the  yolk  sac.  Its  function  is  two- 
fold, first  to  form  the  urinary  bladder,  and,  secondly,  to  aid  in  the 
formation  of  the  placenta.  It  is  with  the  latter  function  that  we 
are  at  present  principally  concerned. 

The  outer  surface  of  the  hypoblastic  sac  is  covered  with  a  layer 


Fig.  6i. — Diagram  to  show  the 
Formation  of  the  Allantois 
as  a  Diverticulum  from  the 
Hind  Gut  of  the  Embryo.' 

The  solid  column  represents  the 
mesoblastic  stalk,  which  extends 
to  the  inner  surface  of  the 
chorion.  The  amnion  is  also 
shown  on  the  dorsum  of  the 
embryo. 


Fig.  62. — A   Later    Stage    than 
Fig.  61. 

The  amnion  has  enlarged,  and  is 
now  almost  co-extensive  with  the 
chorion.  In  consequence  of  the 
closing  in  of  the  limiting  sulci 
the  allantoic  diverticulum  has 
become  oblique.  The  vitelline 
duct  and  the  yolk-sac  are  also 
represented. 


of  splanchno-pleural  mesoblast,  which  in  man  and  in  most 
mammalia  gradually  outstrips  in  growth  the  hypoblast,  and 
forms  the  greater  part  of  the  structure.  It  rapidly  extends 
in  the  form  of  a  solid  stalk  till  it  reaches  the  deep  surface  of 
the  chorion,  to  which  it  conveys  bloodvessels  which  have  passed 
into  it  on  each  side  from  the  primitive  aortse.  These  vessels, 
which  are  termed  the  umbilical  arteries,  at  once  break  up  into 
numerous  branches,  and  the  latter  are  distributed  to  the  chorionic 
villi.  According  to  many  observers,  however,  the  allantois 
appears  at  such  an  early  date  in  the  human  embryo  that  its 
mesoblast  is  never  separated  from  the  mesoblast  of  the  chorion, 
owing  to  the  late  development  of  the  posterior  amniotic  fold. 


THE  DECIDUJE  83 

The  place  where  the  allantoic  stalk  first  abuts  against  the 
chorion  corresponds  to  the  future  situation  of  the  placenta,  and 
over  this  region  the  villi  become  very  much  enlarged,  and  side 
branches  develop  on  the  main  stems,  to  each  of  which  arterial 
twigs  are  given  off.  This  region  is  consequently  known  as  the 
chorion  frondosum,  to  distinguish  it  from  the  remainder  of  the 
chorionic  surface,  which  is  called  the  chorion  lseve.  Over  the 
latter  area,  the  villi  soon  cease  to  grow  and  in  part  atrophy, 
though  occasionally  some  of  them  increase  in  size,  and  establish 
a  firm  union  with  the  uterine  mucous  membrane. 


THE  DECIDU.E 

The   term    decidua   is   applied    to   the    greatly   hypertrophied 
mucous  membrane  of  the  uterus  during  pregnancy,  owing  to  the 


mi 


Fig.  63. — Implantation  of  Ovum  on  the  Decidua. 

Ovum;  2,  uterine  epithelium  ;  3,  connective-tissue  cells  of  decidua; 
4,  capillary  vessels ;  5,  large  clear  cells  of  ovum.  Observe  the  way  in 
which  the  ovum  has  sunk  through  the  epithelium  and  come  in  contact 
with  the  underlying  connective  tissue.     (Grafspee.) 


fact  that  it  is  exfoliated  along  with  the  foetal  membranes  at  the 
close  of  gestation. 

Mammalia  have  been  divided  into  two  main  classes,  non- 
deciduate  and  deciduate,  according  to  the  method  of  attachment 
of  the  placenta  to  the  uterine  wall.  In  the  former  class,  which 
includes  ruminants,  the  placenta  is  represented  by  isolated  groups 
of  chorionic  villi  which  have  only  a  loose  attachment  to  the  mucous 
membrane  of  the  uterus,  and,  consequently,  during  the  expulsion 

6—2 


84  OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 

of  the  contents  of  that  cavity  they  can  become  detached  without 
any  exfoliation  of  the  mucous  membrane  taking  place.  In  the 
latter  class,  the  union  of  the  chorionic  villi  with  the  uterine 
mucous  membrane  is  much  more  intimate,  so  that  when  separa- 
tion occurs  a  part  of  the  membrane  comes  away  with  the  foetal 
structures  and  forms  an  essential  part  of  the  entire  placenta.  In 
fact,  the  separation  takes  place  not  between  the  foetal  placenta  and 


Chorion 


Point  of  origin  of 
decidua  reflexa 


Cavity  of 
uterus 


Fig.  64. 


Os  externum 


-Uterus  with  Ovum  at  the  Third  Month  of  Pregnancy. 
Sagittal  Section.     (Bumm.) 


the  uterine  wall,  but  through  the  mucous  membrane  itself.  In  the 
human  female  the  separation  is  still  more  extensive,  since  the 
superficial  part  of  the  whole  lining  membrane  of  the  uterus,  in 
addition  to  the  placental  part,  is  expelled. 

The  decidua  receives  different  names  according  to  its  relation 
to  the  ovum.  The  latter,  after  its  expulsion  from  the  Graafian 
follicle,  is  received  upon  the  ovarian  fimbria,  and  is  wafted  by  the 
cilia  of  the  cells  covering  the  fimbria,  into  the  Fallopian  tube. 


THE  DECIDU/E  85 

Having  traversed  the  Fallopian  canal,  it  reaches  the  uterus  and 
becomes  embedded  in  the  softened  and  hypertrophied  mucous 
lining,  to  the  whole  of  which  the  term  decidua  vera  is  applied. 
The  latter  becomes  raised  up  all  around  the  ovum,  and  gradually 
grows  over  it  so  as  to  separate  it  from  the  general  cavity  of  the 
uterus.  That  part  of  the  decidua  vera  with  which  the  ovum 
first  comes  in  contact  is  later  called  the  decidua  serotina,  in  con- 
sequence of  the  further  changes  which  take  place  in  it,  and  which 
result  ultimately  in  the  formation  of  the  placenta.  The  part 
which  becomes  reflected  over  the  ovum  is  called  the  decidua 
reflexa,  and,  as  already  stated,  it  separates  the  ovum  from  the 
general  cavity  of  the  uterus,  which  is  lined  by  decidua  vera.  In 
each  of  these  portions,  important  changes  occur  at  the  onset  of 
pregnancy,  and  these  must  now  be  studied. 

Decidua  Vera. — From  the  commencement  of  pregnancy,  a  rapid 
hypertrophic  change  supervenes  in  the  mucous  lining  of  the  entire 
uterus,  and  the  former  continues  to  increase  till  at  the  fifth  month 
it  has  attained  a  depth  of  nearly  half  a  centimetre,  or  about  ten 
times  its  original  thickness.  The  uterine  glands,  which  are  at 
first  simple  tubes  of  nearly  equal  calibre  throughout,  become 
greatly  elongated  and  enormously  dilated  in  their  deeper  parts, 
and  numerous  lateral  outgrowths  spring  from  them.  Their 
mouths  become  dilated  into  funnel-shaped  openings,  which  appear 
as  little  pits  on  the  surface,  but  no  increase  in  size  of  the  lumen 
is  found  in  the  glands  in  the  part  immediately  subjacent  to  the 
surface,  and  they  here  appear  as  elongated  parallel  tubes,  separated 
by  a  considerable  amount  of  intervening  tissue,  in  which  numbers 
of  large  cells,  called  decidual  cells,  are  found.  These  cells  vary 
in  form  and  possess  large  rounded  nuclei.  They  are  connected 
to  one  another  by  cellular  processes,  and  occasionally  become 
aggregated  into  large  clumps.  Some  difference  of  opinion  exists 
regarding  their  origin,  and  by  many  writers  they  are  stated  to  be 
migrated  leucocytes.  According  to  Webster,*  however,  there  is 
no  doubt  that  they  are  derived  by  hypertrophy  and  proliferation 
•from  the  normally  existing  cells  of  the  part.  Their  presence, 
together  with  the  increased  connective  tissue,  causes  the  more 
superficial  portion  of  the  decidua  to  be  firm  and  compact  as 
compared  with  the  deeper  part,  and  it  is  consequently  termed 
the  stratum  compactum. 

In  the  deeper  parts,  where  the  glands  undergo  great  dilatation, 
there  is  but  little  hyperplasia  of  the  supporting  tissue,  and,  when 
sections  are  made  through  it,  it  is  seen  that  the  glands  no  longer 
pursue  a  straight  course,  but  have  become  flattened  out,  often 
with  their  long  axis  parallel  to  the  surface,  and  present  the 
appearance  of  a  network  of  intercommunicating  spaces  separated 
by  intervening  septa.  To  this  part,  the  term  stratum  spongiosum 
is  applied,  and  it  is  through  it  that  the  decidua  becomes  separated 

*  Webster,  J.  C,  'Human  Placentation,'  1901,  p.  18. 


OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 


during  labour.  The  blind  extremities  of  the  glands,  which  are 
in  contact  with  the  muscular  coat  of  the  uterus,  and  which 
do  not  share  in  the  general  dilatation,  are  left  behind  and  prob- 


Mouth  of 

gland- 
Epithelium' 


Stroma- 

Decidual- 

cells 
Capillary- 


\%,  &' 


mil 


?•.!>, 


Stratum 
compactum 


Dilated 
glands 


Stratum 
spongiosum 


Muscular 
wall  of 
uterus 


Fig.  65. — Vertical  Section  through  Decidua  Vera  at  end  of  Third 
Month  of  Pregnancy.     (Bumm.) 

ably  perform  the  function  of  repairing  the  glandular  system 
and  the  surface  epithelium  of  the  uterus  during  the  puerperium. 
The  epithelium  which  lines  the  free  surface  of  the  mucous 
membrane,  as  well  as  that  contained  within  the  glands,  early  loses 


THE  DECIDUM  87 

its  cilise  and  becomes  of  a  low  columnar  or  cubical  type.  Later,  it 
is  found  in  many  places  to  have  disappeared  or  to  persist  as  an 
extremely  flattened  layer,  especially  in  the  spaces  of  the  stratum 
spongiosum. 

The  vessels  of  the  stratum  compactum  show  in  many  places  an 
enormous  capillary  dilatation,  small  sinuses  being  formed  which 
communicate  directly  with  the  veins  and  arteries  passing  through 
the  outer  layer.  These  sinuses  are  lined  by  a  single  endothelial 
layer.     No  special  vascular  change  occurs  elsewhere. 

From  the  end  of  the  fifth  month  onwards  retrogressive  changes 
commence  in  the  decidua  vera,  and  at  the  end  of  pregnancy  it  has 
again  been  reduced  to  a  thickness  of  only  two  millimetres.  The 
compact  layer  almost  entirely  disappears,  becoming  flattened  out 
into  a  number  of  thin  lamellae  of  fibrous  tissue  in  which  no 
glandular  structure  can  be  recognised.  The  mouths  of  the  glands 
also  cease  to  be  visible,  but  in  the  stratum  spongiosum  the  dilated 
spaces  still  appear  as  fissures  in  the  mucous  membrane  separated 
by  strands  of  connective  tissue,  which  have  in  many  places  broken 
down.  The  capillary  sinuses  of  the  compact  layer  still  persist,  but 
have  become  smaller.  This  general  atrophy  of  the  decidua  vera 
in  the  later  months  of  pregnancy  must  be  attributed  to  the 
effects  of  the  pressure  of  the  growing  ovum  upon  it. 

Decidua  Reflexa. — The  decidua  reflexa  has  been  stated  to  be 
formed  by  a  reflection  of  the  mucous  membrane  across  the  ovum 
in  such  a  manner  as  to  completely  encapsule  it.  That  this  is  the 
case  is  proved  by  the  examination  of  some  early  specimens, 
especially  one  recorded  by  Peters, *  in  which  the  ovum  was  only 
about  six  days  old,  and  in  which  the  process  of  infolding  was  not 
complete,  and  also  by  the  fact  that  the  decidua  reflexa  closely 
corresponds  in  structure  with  the  decidua  vera.  The  exact  mode 
of  reflection  of  the  decidua  is,  however,  doubtful,  and  it  now 
appears  probable  that  the  infolding  process  is  more  the  result  of 
the  ovum  sinking  into  the  decidua  than  of  the  decidua  growing 
over  the  ovum.  In  the  early  months  of  pregnancy,  glands  are 
seen  opening  on  both  surfaces  of  the  decidua  reflexa,  and  a 
differentiation  into  stratum  compactum  and  stratum  spongiosum 
is  well  seen  in  those  parts,  which  lie  closest  to  the  uterine  wall. 
Decidual  cells  and  capillary  sinuses  are  also  present.  As  the 
ovum  enlarges,  the  true  cavity  of  the  uterus  becomes  diminished 
in  capacity,  and,  except  in  the  region  of  the  cervix,  has  entirely 
disappeared  after  the  third  month,  owing  to  the  decidua  reflexa 
coming  into  close  contact  with  the  decidua  vera.  Degenera 
tive  changes  then  occur  in  the  former,  as  the  result  of  the 
pressure  to  which  it  is  subjected,  and  it  finally  becomes  reduced 
to  a  very  thin  membrane,  which  is  even  in  some  places  deficient, 
so  that  the  amnion  and  chorion  come  directly  into  relation  with 
the  decidua  vera. 

*  Peters, "' Ueber  d.  Einbettung  d.  menschl.  Eies.,'  Wien,  1899. 


88         OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 

Decidua  Serotina. — In  the  decidua  serotina,  the  early  changes 
lead,  as  elsewhere,  to  a  separation  into  a  stratum  compactum  and 
a  stratum  spongiosum.  The  glands  in  the  latter  become  com- 
pletely flattened  out,  and  their  epithelium  disappears,  except  in 
a  narrow  basal  zone  attached  to  the  muscular  coat.  In  the 
stratum   compactum,  the  glands  entirely  disappear  at  an  early 


>\ypu.x  wi 


ft 


: 


Fig.  66.- — Section  showing  Chorionic  Villi  extending  into  Decidua 

Serotina. 

i,  Gland;  2,  capillaries  of  serotina;  3,  syncytial  processes  in  a  maternal 
capillary  ;  4,  syncytium  ;  5,  chorionic  villi  with  syncytium  ;  6,  capil- 
laries of  villi.     (Bumm.) 


date,  and  after  the  sixth  week  none  of  the  covering  layer  of 
epithelial  cells  can  be  demonstrated.  It  is  through  the  zone  of 
flattened  out  gland  spaces  that  separation  of  the  placenta  takes 
place,  while  in  connection  with  the  more  superficial  parts  very 
important  changes  occur,  which  will  be  discussed  immediately  in 
connection  with  the  placenta,  of  which  they  form  a  part. 


THE  PLACENTA 


THE  PLACENTA 


The  placenta  at  term  is  an  excessively  vascular  structure  of 
an  irregular  oval  or  discoid  shape,  composed  partly  of  altered 
uterine  mucous  membrane  (placenta  uterina)  and  partly  of  highly 
developed  chorionic  villi  (placenta  fcetalis).  Its  diameter  is  from  six 
to  eight  inches.  It  is  usually  thickest  in  the  centre,  where  it  attains 
a  depth  of  a  little  over  one  inch,  and  thins  out  towards  the  edges, 
to  which  are  attached  the  amnion  and  chorion,  together  with  the 
remains  of  the  uterine  decidua.  In  some  cases,  however,  it  is  of 
almost  equal  thickness  throughout  its  whole  extent.  In  weight  it 
varies  from  one  to  one  and  a  half  pounds.  It  is  most  frequently 
situated  in  the  region  of  the  fundus  of  the  uterus,  usually  to  one 
side  of  the  middle  line,  and  occasionally  covers  over  the  ostium 
internum  of  one  of  the  Fallopian  tubes.  The  surface,  which  is 
turned  towards  the  foetus,  is  smooth  and  covered  by  amnion, 
under  which  can  be  seen  ramifying  large  branches  of  the  umbilical 
arteries  and  vein,  of  which  the  former  lie  superficially  and  cover 
over  the  latter.  The  uterine  surface,  on  the  contrary,  is  irregular, 
and  presents  a  number  of  lobular  projections  or  cotyledons 
separated  from  one  another  by  shallow  intervening  furrows.  The 
cotyledons  correspond  to  groups  of  chorionic  villi,  as  will  be 
more  fully  appreciated  when  the  method  of  development  and  the 
microscopical  structure  of  the  organ  have  been  studied. 

The  chorionic  membrane  in  the  early  stages  of  its  existence  is 
covered  almost  uniformly  with  small  villi,  which  project  into  pits 
in  the  decidua  serotina  and  decidua  reflexa  between  the  openings 
of  the  uterine  glands.  At  first,  there  is  no  mesoblast  within  the 
villi.  They  are,  in  fact,  formed  entirely  by  the  proliferation  of 
the  cells  which  form  the  outer  epiblastic  portion  of  the  chorion. 
To  these  cells  Hubrecht  has  given  the  name  '  trophoblast,'*  since 
they  appear  to  exert  upon  the  decidua  some  absorptive  influence, 
which  enables  them  to  form  the  depressions  in  which  they  are 
placed.  As  soon  as  the  allantois  with  its  arteries  has  reached 
the  deep  surface  of  the  chorion,  a  branch  of  the  umbilical  artery 
is  given  to  each  villus,  in  which  it  breaks  up  into  capillaries. 
From  the  villi,  the  blood  is  again  collected  by  small  veins,  which 
are  tributary  to  the  umbilical  vein.  As  early  as  the  third  week 
it  is  noticed  that  the  villi  in  relation  to  the  decidua  serotina  are 
larger  than  those  which  cover  the  remainder  of  the  chorion. 
The  latter  at  first  are  related  to  the  reflexa  in  a  manner  similar 
to  what  is  found  in  the  serotina,  and  are  bathed  with  maternal 
blood  contained  in  the  dilated  capillaries  of  the  stratum  compac- 
tum  ;  but,  after  the  sixth  week,  they  show  signs  of  degeneration, 
and  at  a  later  date  are  found  to  be  almost  entirely  atrophied, 

*  Hubrecht,  '  Die  Phylogenese  d.  Amnions  und  d.  Bedeutung  d.  Tropho- 
blasts.' 


go         OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 

while  the  chorion  has  become  directly  united  to  the  thinned  out 
reflexa. 

In  the  placental  region,  on  the  contrary,  the  villi  become  much 
enlarged,  and  from  all  sides  of  the  main  stem  small  vascularized 
branches  bud  off,  so  that  very  complex  villous  processes  are 
produced.  The  main  stem  is  embedded  in  the  uterine  mucous 
membrane,  and  so  also  are  some  of  the  lateral  offshoots,  but 
many  of  the  latter  hang  free  in  a  space  intervening  between  them- 
selves and  the  decidua.  This  space  is  supposed  to  contain 
maternal  blood,  and  to  form  a  series  of  intercommunicating  blood 
sinuses.  Each  villus  is  now  composed  of  a  central  stalk  con- 
taining bloodvessels  embedded  in  a  gelatinous  connective  tissue 
derived  from  the  chorionic  mesoblast,  and  is  covered  by  a  double 
layer  of  epithelial  cells,  both  of  which  are  derived  from  the 
original  mesoblast.  The  innermost  of  these  two  layers,  that 
which  lies  next  the  mesoblastic  stalk  (endochorion),  is  composed 
of  a  single  layer  of  clearly  differentiated  cells,  round  or  cubical  in 
form,  and  containing  well  -  developed  nuclei.  It  is  known  as 
Langhans'  layer,  after  the  name  of  the  authority  who  first 
described  it.  The  cells  which  form  it  do  not  stain  well  with  the 
ordinary  aniline  dyes.  In  the  outer  layer  no  division  into  indi- 
vidual cells  can  be  made  out,  because  the  cells  have  run  together 
into  plasmodial  masses  of  granular  protoplasm,  which  contain, 
arranged  irregularly  within  them,  numerous  deeply- staining 
nuclei.  This  layer  was  originally  supposed  to  be  maternal  in 
origin,  and  to  represent  the  epithelial  covering  of  the  uterine 
mucous  membrane,  but  it  is  now  definitely  proved  that  such  a 
covering  entirely  disappears  at  a  very  early  date,  and  most 
authorities  are  agreed  that  the  origin  of  the  syncytium,  as  the 
layer  is  called  on  account  of  its  characteristics,  is  as  above  stated. 
It  is  the  syncytium  which  forms  the  primitive  villi,  and  to  which 
the  term  '  trophoblast '  is  given.  As  the  cells  which  form  it  pro- 
liferate, the  villi  project  into  the  decidua,  and,  causing  an  absorp- 
tion of  that  structure,  they  come  in  contact  with  the  blood  sinuses 
of  the  stratum  compactum.  Vacuolation  followed  by  absorption 
then  occurs  in  the  cells  of  the  trophoblast,  so  as  to  form  spaces 
between  the  different  branches  of  the  villi,  and  it  is  these  spaces 
which  become  filled  up  with  blood  and  constitute  an  extension  of 
the  maternal  sinuses,  while  at  the  same  time  the  deeper  layers  of 
the  trophoblast  assume  syncytial  characters. 

The  exact  mode  in  which  these  spaces  become  dilated  with 
maternal  blood  is  still  a  matter  of  doubt.  Many  authorities 
believe  that  the  trophoblast  is  capable  of  absorbing  the  endo- 
thelial walls  of  the  capillaries  as  well  as  the  tissue  of  the  uterine 
decidua,  and  that  blood  becomes  effused  into  the  spaces  by  the 
direct  rupture  of  the  capillary  walls.  It  appears,  however,  more 
probable  that  the  capillary  sinuses  themselves  dilate  pari  passu 
with  the  disappearance  of  the  trophoblast,  and  thus  come  to 
occupy  the  intervillous  spaces.     If  this   is  the  case,  a  layer  of 


THE  PLACENTA 


9> 


vascular  endothelium  lining  the  capillary  walls  should  be  found 
on  the  surface  of  the  syncytium  separating  the  foetal  tissues  from 
the  blood  of  the  mother,  and  although  this  has  not  been  con- 
clusively demonstrated,  there  is  some  evidence  of  its  existence  at 
an  early  date.  Such  a  layer  of  cells  from  its  extreme  tenuity 
may  readily  become  atrophied  later  on  as  a  result  of  the  pressure 
to  which  it,  in  common  with  the  other  parts  of  the  uterine  mucous 


Fig.  67. — Chorionic  Villi  of  a  Five  Weeks'-Old  Ovum. 

A,  Longitudinal  section;  B,  cross-section.  1,  Langhans'  layer;  2,  syncy- 
tium; 3,  syncytial  outgrowth;  4,  foetal  capillary;  5,  stroma  of  villus. 
(Bumm.) 


membrane,  becomes  subjected  from  the  growth  of  the  foetus  and 
the  intermittent  contractions  of  the  uterus  itself.  It  is  also  quite 
credible  that,  atypically,  rupture  of  capillaries  may  occur  in  conse- 
quence of  the  extremely  rapid  dilatation  which  they  undergo, 
and  that  in  some  places  a  genuine  extravasation  of  blood  may 
take  place. 

If   the     deeper    parts    of    the    decidua    serotina    are    studied 


92 


OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 


subsequent  to  the  formation  of  the  sinuses,  numerous  spirally 
twisted  arteries  are  found  traversing  the 'stratum  spongiosum 
and  opening  into  the  blood  spaces.  Intervening  between  these, 
as  they  lie  in  the  stratum  compactum,  there  are  a  large 
number  of  so-called  giant  cells.  It  is  probable  that  these  giant 
cells  are  really  the  extremities  of  foetal  villi  cut  transversely. 
They  are  specially  abundant  in  the  later  months  of  pregnancy, 
and  are  supposed  to  obstruct  the  flow  of  blood  in  the  smaller 
venules  just  before  labour.  As  the  arteries  pass  through  the 
stratum  compactum  just  before  they  communicate  with  the  blood 
sinuses,  they  lose  their  distinctive  arterial  characters  and  come 
to   resemble  veins.     The   blood  which    flows   in   through   these 


v  Choronic 
V      villi 


Fig.  68. — Diagrammatic  Representation  of  Portion  of  Placenta. 

(Bumm.) 

i,    Muscular    coat    of    uterus;    2,    maternal    arteries;    3,    maternal   veins; 

4,  decidua ;  5,  mouth  of  artery  ;  6,  inter-villous  space. 


efferent  channels  traverses  the  space  between  the  chorion  and 
decidua,  flowing  in  a  slow  continuous  stream  which  bathes  the 
chorionic  villi,  and  emerges  by  small  afferent  vessels  which  open 
into  veins  contained  in  the  stratum  spongiosum.  Around  the 
circumference  of  the  placenta,  the  sinuses  communicate  freely 
with  one  another  by  means  of  a  circumferential  marginal  sinus. 
All  of  the  spaces,  including  this  marginal  sinus,  can  be  injected 
through  the  maternal  bloodvessels,  but  there  is  in  no  place  any 
direct  communication  between  the  foetal  and  maternal  blood 
systems.  The  foetal  blood  is  separated  from  that  of  the  mother  by 
(1)  the  syncytium,  (2)  Langhans'  layer,  (3)  chorionic  connective 
tissue,  (4)  endothelium  of  fcetal  capillaries. 

In  the  foregoing  description  of  the  placental  structure  it  has 


THE  FUNCTIONS  OF  THE  PLACENTA 


9i 


been  stated  that  in  the  latter  half  of  pregnancy  the  chorionic  villi 
float  in  the  maternal  blood,  and  are  in  direct  contact  with  it,  with- 
out the  interposition  of  any  decidual  tissue,  and  this  is  the  generally 
received  view.  It  is,  however,  only  right  to  state  that  some 
writers  adhere  to  the  opinion  that  the  spiral  arteries  really  ter- 
minate in  dilated  capillaries  in  the  stratum  spongiosum,  and  that 
intervening  between  them  and  the  villi  a  layer  of  decidual  tissue 
exists  which  is  credited  with  a  glandular  function.  This  layer  is, 
in  fact,  supposed  to  exercise  a  selective  absorptive  power  upon  the 
constituents  of  the   maternal  blood,  and  to  secrete,  in  the  form 


Fig.  69. — Diagrammatic    Section    through  Uterine  Wall   and 
Placenta. 

Uterine  artery  opening  into  inter-villous  space;  2,  3,  mouth  of  vein; 
4,  muscular  wall  of  uterus;  5,  decidual  septa;  6,  decidua ;  7,  decidua 
vera;  8,  sub-chorionic  decidua  ;  9,  inter-villous  spaces  ;  10,  foetal  villus  ; 
ii,  chorion  and  amnion  ;  12,  umbilical  cord.  The  relations  of  the  fcetal 
villi  to  the  maternal  blood  bath  are  well  shown.  Observe  also  the  dilated 
maternal  veins.     (Bumm.) 


of  lymph,  the  materials  which  it  has  taken  up  around  the  villi, 
into  whose  bloodvessels  it  is  absorbed.  Whatever  is  the  exact 
mode,  however,  in  which  nutritive  material  is  transferred  from 
the  mother  to  the  ovum,  there  is  no  doubt  about  the  important 
part  which  the  placenta,  as  a  whole,  plays  in  the  process,  and 
about  its  power  of  selecting  one  substance  and  rejecting  another, 
according  to  the  requirements  of  the  foetus  at  different  periods. 

Functions  of  the  Placenta. — The  placenta  acts  as  the  organ  of 
respiration,  nutrition,  and  excretion  to  the  growing  foetus.  Venous 
blood  is  conveyed  to  the  chorionic  villi  by  means  of  the  umbilical 
arteries,  and  then  absorbs  oxygen  from  the  maternal  blood,  while 


94         OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 

at  the  same  time,  either  by  a  process  of  diffusion  or  by  means 
of  the  selective  activity  of  the  cells  covering  the  villus,  carbon 
dioxide  gas  is  conveyed  to  the  maternal  circulation.  The  actual 
amount  of  gaseous  exchange  is  not  very  great,  and,  consequently, 
very  little  difference  of  colour  can  be  noted  between  the  blood  in 
the  umbilical  vein  and  arteries,  but  oxyhemoglobin  is  more  easily 
detected  by  the  spectroscope  in  the  blood  in  the  former  of  these 
vessels.  That  the  placenta  does  carry  out  the  function  of  oxygena- 
tion is  proved,  if  in  no  other  way,  by  the  fact  that  if  the  cord  be 
compressed  during  labour  and  the  circulation  in  its  vessels  inter- 


V 


Fig.  70. — Placenta   at   Fdll  Term,   showing  Superficial  Distribution 
of  Bloodvessels.     (Minot,) 


rupted,  as  frequently  occurs  in  breech  presentations,  attempts  at 
respiration  by  the  lungs  are  almost  immediately  made,  due  to 
stimulation  of  the  respiratory  centre  in  the  medulla  by  the 
increasing  venosity  of  the  blood.  A  similar  stimulus  aids  in 
bringing  about  the  first  respiration  after  birth  in  normal  cases, 
even  before  the  cord  is  cut,  owing  to  the  arrest  of  the  maternal 
circulation  in  the  placenta  brought  about  by  the  uterine  contrac- 
tions. Not  only  can  oxygen  and  carbon  dioxide  gas  pass  through 
the  placenta,  but  also  such  substances  as  alcohol — as  has  been 
proved  by  experiments  on  animals— and  chloroform.  In  some 
cases  in  which  the  latter  is  used  as  an  anaesthetic  during  labour, 


THE  FUNCTIONS  OF  THE  PLACENTA  95 

the  smell  of  chloroform  can  be  detected  in  the  breath  of  the  child 
for  some  hours  after  delivery. 

In  addition  to  its  respiratory  function,  the  placenta  also  permits 
the  passage  of  a  large  amount  of  the  waste  materials  derived 
from  the  proteid  metabolism  of  the  foetus,  and  of  which  urea 
probably  forms  the  greatest  part,  and  also  enables  nutritive 
material  to  pass  from  the  maternal  blood  to  that  of  the  foetus. 
In  this  latter  function  it  exhibits  considerable  power  of  selection, 
and  it  is  now  almost  certain  that  the  quantity  and  quality  of  the 
different  materials  absorbed  vary  in  accordance  with  the  require- 
ments of  the  foetus  at  different  periods.  Thus,  during  the  later 
months  of  pregnancy  a  considerable  storage  of  iron  accumulates 
within  the  foetus,  and  serves  as  a  reserve  for  the  future  formation 
of  haemoglobin.  During  the  same  period  a  relatively  large 
amount  of  potassium  and  calcium  salts  pass  from  the  mother 
to  the  foetus,  as  has  been  proved  by  analyses  of  foetal  tissues 
at  different  months.  The  potassium  and  calcium  salts  are 
evidently  required  for  the  great  muscular  and  skeletal  develop- 
ment which  is  going  on  during  the  later  months  of  pregnancy. 
That  the  passage  of  materials  does  not  merely  depend  upon  their 
solubility,  is  shown  by  the  fact  that  there  is  a  larger  percentage  of 
glucose  in  the  blood  of  the  mother  than  in  that  of  the  child. 

Analysis  of  the  placenta  shows  that  four-fifths  of  it  is  composed 
of  water,  and  that  it  contains,  in  addition  to  the  salts  and  albu- 
minous materials  within  it,  a  comparatively  large  amount  of 
glycogen.  This  latter  fact  has  caused  a  glycogenic  function  to 
be  attributed  to  it. 

In  addition  to  the  above  functions,  the  placenta  must  in  some 
ways  act  as  a  protection  to  the  foetus,  by  arresting  the  passage 
of  microbic  and  toxic  substances.  The  protective  power  is  not 
highly  developed,  however,  and  may  be  easily  broken  down,  as  is 
shown  by  the  transmission  of  the  infective  agent  of  syphilis  and 
of  the  germs  of  the  various  zymotic  diseases  from  which  the 
mother  may  suffer  during  pregnancy.  Possibly  such  germs  are 
carried  across  by  leucocytes,  which  are  supposed  to  have  the 
power  of  migrating  from  the  maternal  blood  to  that  of  the  foetus, 
on  account  of  their  being  found  in  greater  numbers  in  the  blood 
of  the  umbilical  vein  than  in  that  of  the  arteries. 

Recently,  it  has  been  stated  by  Bouchard  that  the  placenta 
furnishes  an  internal  secretion  formed  within  the  cells  of  the 
syncytium,  and  which  has  a  specific  galactagogue  power.  He 
has  isolated  a  substance  which  he  terms  chorionine,  from  the 
juice  of  fresh  placentae,  and  states  that  he  has  observed  favour- 
able results  from  its  administration  in  patients  who  were  suffer- 
ing from  defective  mammary  secretion.  His  results  are  not 
improbable,  but  require  confirmation. 


96         OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 


THE  UMBILICAL  CORD 

The  umbilical  cord  constitutes  the  bond  of  union  between  the 
foetus  and  the  placenta,  extending  from  the  umbilicus  of  the  former 
to  the  centre  of  the  amniotic  surface  of  the  latter.  Its  length 
is  usually  about  twenty  inches,  but  it  varies  within  wide  limits, 
having  been  found  as  short  as  five  inches  and  as  long  as  five  feet. 
In  cases  of  congenital  absence  of  the  anterior  abdominal  wall  in- 
deed, due  to  defective  closing  in  of  the  primitive  limiting  sulci,  the 
foetus  may  be  directly  united  to  the  placenta  and  the  cord  com- 
pletely absent.  In  the  early  stages  of  gestation,  the  cord  is  short, 
and  the  foetus  then  appears  to  be  suspended  by  it  within  the 
amniotic  fluid,  but  as  the  amnion  enlarges  the  cord  becomes 
longer  and  lies  in  folds  within  the  amniotic  cavity. 

The  cord  usually  presents  a  series  of  spiral  twists  from  left  to 


Fig.  71. — Umbilical  Cord,  showing  Vessels. 

A,  Umbilical  arteries  coiling  spirally  around  the  umbilical  vein ;  B,  section 
through  cord,  showing  the  arteries  at  the  sides  of  the  vein  and  a  valvular 
fold  in  the  vein.     (Tarnier  and  Chantreuil.) 

right,  which  have  been  attributed  by  some  authors  to  rotation  of 
the  foetus  in  utero.  Such  an  explanation  is,  however,  inadequate, 
as  it  fails  to  show  why  rotation  should  always  take  place  in  the 
same  direction.  Apart  from  undoubted  cases  of  axial  rotation, 
which  not  infrequently  occur,  and  usually  cause  the  death  of  the 
foetus  by  obliteration  of  the  lumen  of  the  umbilical  vessels,  it  is 
probable  that  the  twist  is  only  a  surface  marking  produced  by  the 
course  of  the  arteries  within  the  cord.  Small  hernia- like  projec- 
tions are  also  very  frequently  seen  on  the  surface  of  the  cord,  and 
are  caused  either  by  hypertrophy  of  the  connective  tissue  in 
places,  or  by  local  dilatations  of  the  vein.  Occasionally,  even 
true  knots  are  found.  When  these  are  formed  during  expulsion 
of  the  foetus  no  diminution  of  the  calibre  of  the  cord  is  found  at 
the  place  where  they  exist,  but  if  they  occur  at  an  earlier  date 
they  usually  give  rise  to  marked  indentations  of  the  cord,  the 
result    of  pressure   atrophy   of    its   connective  tissue.     In  some 


THE  UMBILICAL  CORD  97 

cases,  they  may,  indeed,  become  so  tight  as  to  arrest  circulation 
within  the  umbilical  vessels  and  to  bring  about  the  death  of  the 
foetus,  while  if  any  part  of  the  foetus  lies  within  the  knct  strangula- 
tion of  it  may  result. 

The  cord  is  surrounded  superficially  by  a  covering  of  amnion, 
which  blends  in  the  region  of  the  umbilicus  with  the  skin  of  the 
abdominal  wall,  and  on  reaching  the  placenta  spreads  out  on  its 
deep  surface  over  the  umbilical  bloodvessels.  It  is  by  the 
gradual  deepening  of  the  limiting  sulci  and  consequent  closing  in 
of  the  line  of  reflection  of  the  amnion  on  the  ventral  surface  of 
the  embryo  that  the  various  structures  which  form  the  cord  are 
brought  together.  The  constituents  are  the  two  umbilical  arteries, 
the  umbilical  vein,  and  the  remnants  of  the  vitelline  and  allantoic 
ducts,  all  of  which  are  bound  together  by  a  gelatinous  connec- 
tive tissue  known  as  the  Whartonian  jelly,  and  which  lies  enclosed 
within  the  amniotic  sheath. 

The  umbilical  arteries  arise  in  the  pelvis  of  the  foetus  from  the 
trunks  of  the  internal  iliac  arteries,  and  passing  upwards  on  the 
posterior  aspect  of  the  anterior  abdominal  wall,  enter  the  cord  at 
the  umbilicus.  They  present  within  the  cord  a  spiral  twist  fvom 
left  to  right,  corresponding  to  that  which  has  been  already  noticed 
in  connection  with  the  cord  itself,  and  lie  superficially  surrounding 
the  vein.  Their  twisted  course  probably  serves  to  check  the 
pulsation  of  the  blood-stream  before  they  reach  the  villi.  Just 
before  reaching  the  placenta,  the  arteries  are  frequently  connected 
by  a  transverse  communicating  branch.  On  the  placenta  itself, 
they  break  up  into  numerous  branches  which  lie  superficial  to 
the  veins  and  are  distributed  freely  to  the  chorionic  villi.  The 
arteries  have  a  thick  muscular  wall  and  a  well-marked  power  of 
contraction. 

The  umbilical  vein  is  single.  At  first,  two  veins  exist,  but  at 
a  very  early  date  in  pregnancy  the  two  become  fused  within  the 
cord  into  a  single  trunk,  which  enters  the  abdomeu  of  the  foetus 
and  passes  upwards  in  the  falciform  ligament  of  the  liver.  It 
occupies  a  central  position  within  the  cord  and  is  devoid  of  com- 
plete valves. 

In  the  earlier  months  of  pregnancy,  the  remains  of  the  vitelline 
and  allantoic  ducts  can  usually  be  demonstrated  within  the  cord 
as  columns  of  epithelial  cells,  and  accompanying  the  former  may 
be  seen  small  vitelline  bloodvessels.  At  term,  however,  these 
structures  have  almost  entirely  disappeared,  though  when  sections 
are  made  traces  of  their  presence  may  be  found  here  and  there  in 
the  form  of  small  islets  of  epithelial  cells.  Occasionally,  even  the 
umbilical  vesicle  or  yolk  sac  may  be  found  as  a  minute  sac  lying 
between  the  amnion  and  the  chorion  near  the  margin  of  the 
placenta. 

The  jelly  of  Wharton,  which  serves  to  bind  together  the 
foregoing  structures,  is  chiefly  composed  of  stellate  cells  which 
are  covered  with  branching  and  anastomosing  processes.     Con- 

7 


98  OBSTETRICAL  AN  ATOMY.— MATERNAL  AND  OVULAR 

nective-tissue  strands  and  elastic  fibres  can  also  be  demonstrated 
within  it.     The  amnion  is  closely  adherent  to  its  substance. 


THE  LIQUOR  AMNII 

The  liquor  amnii  is  alkaline  in  reaction  and  has  a  specific 
gravity  of  from  1007  to  1011.  In  quantity,  it  averages  about 
three  pints,  but  wide  variations  exist.  It  is  at  first  clear  and 
transparent,  but  towards  the  end  of  pregnancy  it  becomes  darker 
in  colour  and  somewhat  turbid.  On  analysis,  it  is  found  to  contain 
about  97  per  cent,  of  water,  together  with  traces  of  albumin, 
grape-sugar,  urea,  and  various  salts  of  potassium,  sodium, 
calcium,  magnesium,  and  ammonium.  Traces  of  albumoses 
and  peptones  have  also  been  detected.  Floating  within  it,  are 
found  lanugo  hairs  and  desquamated  epithelium  from  the  foetal 
epidermis. 

The  exact  origin  of  the  liquor  amnii  is  still  a  matter  of  doubt. 
At  different  times  it  has  been  supposed  to  be  derived  from  the 
mother  alone  and  from  the  foetus  alone.  Probably,  however,  it 
is  really  derived  from  both  maternal  and  foetal  sources,  though 
without  doubt  the  greater  part  of  it  is  formed  by  transudation 
from  the  vascular  system  of  the  mother.  Drugs  given  to  the 
mother  {e.g.,  potassium  iodide)  can  often  be  detected  subsequently 
in  the  fluid.  The  presence  of  urea  seems  to  point  to  its  receiving 
the  secretion  of  the  foetal  kidneys ;  but  that  this  is  an  accidental 
rather  than  an  essential  occurrence  as  far  as  the  fluid  itself  is 
concerned  is  proved  by  the  fact  that  the  liquor  amnii  is  not  neces- 
sarily, or  indeed  often,  deficient  in  cases  in  which  the  ureters  or 
urethra  are  imperforate.  Those  authorities  who  believe  that  the 
fluid  is  entirely  foetal  in  origin  hold  that  it  is  exuded  early  in 
pregnancy  from  a  system  of  capillary  vessels  on  the  foetal  side  of 
the  placenta — the  vasa  propria  of  Jungbluth,  and  point  out  that 
the  persistence  of  these  capillaries  is  associated  with  hydramnios. 
Their  statements,  however,  lack  sufficient  evidence,  though  it  is 
extremely  probable  that  a  small  amount  of  the  fluid  is  derived 
from  this  capillary  plexus,  and  also  from  the  vessels  in  the  umbi- 
lical cord  itself. 

The  functions  of  the  amniotic  fluid  are  important  both  during 
gestation  and  during  labour.  Being  a  bad  conductor  of  heat,  it 
serves  during  pregnancy  to  maintain  an  equable  temperature 
around  the  foetus,  and  at  the  same  time  its  presence  diminishes 
the  transmission  of  shocks  and  allows  room  for  the  foetal  move- 
ments. Possibly,  it  exerts  a  slight  nutritive  function,  and  many 
believe  that  it  is  swallowed  by  the  foetus  during  the  later  months 
of  pregnancy  in  large  quantities.  During  labour,  it  acts  as  a  fluid 
dilator  of  the  cervix,  and  prevents  the  contracting  uterus  from 
exerting  injurious  pressure  upon  the  child. 


CHAPTER    IV 
THE  F(ETUS 

The  Physiology  of  the  Foetus ;  The  Circulatory  System ;  The  Digestive 
System  ;  The  Nervous  System — The  Characteristics  of  the  Foetus  at  the 
Different  Months  —  The  Full-Term  Foetus;  General  Characteristics; 
Height  and  Length  ;  The  Foetal  Skull,  General  Characteristics,  Sutures, 
Fontanelles,  Diameters,  Circumferences,  Regions  ;  The  Foetal  Trunk — 
The  Relations  of  the  Foetus  to  the  Uterus  :  Attitude;  Lie;  Presentation; 
Position. 


THE  PHYSIOLOGY  OF  THE  FCETUS 

The  Circulatory  System.  —  During  its  development,  the  foetus 
passes  through  at  least  three  distinct  stages  as  regards  its  method 
of  obtaining  nutrition  :  (a)  A  primary  stage,  during  which  it 
directly  absorbs  nourishment  from  the  albuminous  envelope 
surrounding  it,  and,  according  to  some  authorities,  from  the 
uterine  wall  by  means  of  primitive  villi  formed  upon  the  zona 
pellucida ;  (b)  a  secondary  stage,  in  which  the  vitelline  circula- 
tion is  established  and  the  contents  of  the  yolk  sac  are  thereby 
utilized  ;  (c)  a  tertiary  stage,  subsequent  to  the  formation  of  the 
placenta,  and  during  which,  that  structure  enables  the  foetus  to 
derive  its  food-supply  from  the  maternal  blood. 

In  order  that  the  nourishment  obtained  in  this  last  method 
may  be  expended  to  the  greatest  advantage  of  the  foetus,  several 
important  structural  differences  are  present  in  its  vascular  system, 
as  compared  with  those  found  in  extra-uterine  life.  The  course 
of  the  blood,  as  determined  by  these  structures,  prevents  any 
definite  separation  into  systemic  and  pulmonary  systems,  and 
leads  to  a  considerable  mixture  of  venous  and  arterial  blood. 
These  modifications  may  be  dealt  with  seriatim  : — 

The  foramen  ovale  is  a  wide  aperture,  which  exists  in  the 
interauricular  septum,  and  brings  the  two  auricles  into  communi- 
cation with  one  another.  It  is  somewhat  valvular  in  character, 
and  permits  blood  to  flow  from  the  right  to  the  left  side,  but  not 
in  the  opposite  direction.  Towards  full  term,  it  diminishes  some- 
what in  size.  Leading  down  from  its  anterior  margin  to  the 
inferior   vena  cava  is  a  small   fold  of   endocardium,   called   the 

99  7—2 


ioo       OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 

Eustachian  valve,  which  directs  the  blood  entering  the  auricle 
through  the  inferior  vena  cava  towards  the  foramen. 

The   ductus   arteriosus    is    a    wide,    communicating    channel 
which  exists  between  the  pulmonary  artery  and  the  aorta,  being 


Fig.  72. — Diagrammatic  Representation  of  Foetal  Circulation. 

a,  Superior  vena  cava  ;  b,  pulmonary  artery;  c,  descending  aorta  ;  d,  inferior 
vena  cava  ;  e,  hepatic  vein ;  /,  umbilical  vein ;  g,  hypogastric  artery  ; 
h,  inferior  vena  cava;  i,  descending  aorta. 

connected  with  the  former  just  at  its  point  of  bifurcation,  and 
with  the  concavity  of  the  arch  of  the  latter.     It  enables  the  blood 


THE  FCETAL  CIRCULATION  101 

in  the  pulmonary  artery  to  enter  the  arch  just  below  the  point  of 
origin  of  the  left  subclavian  artery. 

The  hypogastric  arteries  arise  from  the  common  iliac 
arteries,  and  pass  forwards  along  the  side  of  the  bladder  to  the 
posterior  aspect  of  the  anterior  abdominal  wall,  along  which  they 
ascend  till  they  reach  the  umbilicus.  Their  extra-foetal  portion 
within  the  umbilical  cord  has  been  already  described. 

The  umbilical  vein  enters  the  abdomen  at  the  umbilicus, 
and  passes  along  the  under  surface  of  the  liver  within  the  fold  of 
the  falciform  ligament  of  the  latter,  to  the  portal  vein.  A  con- 
tinuation of  it  then  passes  from  the  opposite  side  of  the  portal 
vein  to  the  inferior  vena  cava,  and  is  known  as  the  ductus 
venosus. 

In  the  full-term  foetus,  the  course  of  the  blood  is  as  follows : — 
Arterial   blood  from  the  placenta  flows  along  the  umbilical  vein 


u^ 


Fig.  73. — Diagrammatic  Representation  of  Fcetal  Heart. 

a,  Superior  vena  cava  ;  b,  pulmonary  artery  ;  c,  descending  aorta  ;  d,  inferior 
vena  cava.  The  arrow  leading  from  the  orifice  of  the  inferior  vena  cava 
is  directed  towards  the  foramen  ovale. 


to  its  junction  with  the  portal  vein,  where  the  current  divides 
into  two  channels,  a  small  part  passing  with  the  blood  from  the 
intestinal  tract  through  the  liver  by  means  of  the  portal  vein, 
and  flowing  ultimately  through  the  hepatic  veins  into  the  inferior 
vena  cava  at  the  upper  surface  of  that  organ.  The  remainder 
flows  through  the  ductus  venosus  directly  into  the  inferior  vena 
cava.  At  first,  the  entire  current  of  blood  flows  into  the  portal 
vein,  but  as  the  umbilical  vein  increases  in  size,  in  correspondence 
with  the  increasing  amount  of  blood  flowing  through  it,  the  portal 
system  becomes  insufficient  for  its  transmission,  and  the  ductus 
venosus  becomes  developed.  This  short  circuiting  of  the  current 
is  obviously  of  advantage,  by  enabling  the  greater  amount  of  the 
arterial  blood  to  pass  directly  to  the  heart,  where  it  can  be  dis- 


102       OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 

tributed  to  the  cephalic  region  of  the  embryo,  without  being 
previously  deoxygenated  in  the  liver.  The  entire  amount  of 
blood  which  flows  into  the  right  auricle  through  the  inferior 
vena  cava,  representing  the  blood  from  the  placenta,  that  of  the 
portal  system,  and  the  blood  from  the  lower  limbs,  is  directed  by 
means  of  the  Eustachian  valve  and  the  tubercle  of  Lower  through 
the  foramen  ovale  into  the  left  auricle,  from  whence  it  is  driven 
into  the  left  ventricle.  From  this  latter  chamber  it  is  pumped 
into  the  aorta,  and  is  almost  entirely  distributed  by  means  of  the 
carotid  and  subclavian  arteries  to  the  head  and  upper  limbs,  so 
that  these  regions  of  the  body  obtain  the  purest  blood  that  is 
driven  from  the  heart. 

The  blood,  returning  from  the  upper  parts  of  the  body  through 
the  innominate  veins,  enters  the  right  auricle  by  the  superior  vena 
cava,  and  passes  on  into  the  right  ventricle,  whence  it  is  pumped 
into  the  pulmonary  artery.  A  small  part  of  this  current  then 
flows  through  the  right  and  left  pulmonary  arteries  into  the  lungs, 
and  returns  to  the  left  auricle  through  the  pulmonary  veins  ;  but, 
by  far  the  greater  proportion  is  directed  through  the  ductus 
arteriosus  into  the  aorta,  below  the  level  at  which  the  trunks  for 
the  upper  part  of  the  body  arise,  and  consequently  flows  down- 
wards in  the  descending  aorta  to  supply  the  abdominal  viscera 
and  the  lower  limbs.  In  addition  to  this  distribution,  a  consider- 
able proportion  of  the  current  flows  through  the  hypogastric 
arteries  to  the  placenta. 

In  association  with  the  fact  that  the  head  receives  the  best 
oxygenated  blood,  it  is  found  at  birth  to  be  developed  much  more 
in  proportion  than  the  other  parts  of  the  body.  The  liver  also 
receives  some  arterial  blood  directly  from  the  placenta,  and  is 
correspondingly  large. 

As  the  foetus  approaches  full  term,  slight  narrowing  of  the 
foramen  ovale  and  of  the  ductus  arteriosus  takes  place,  prepara- 
tory to  the  establishment  of  two  distinct  circuits,  pulmonary  and 
systemic,  and  immediately  after  delivery  very  important  changes 
occur.  The  cessation  of  the  placental  circulation  diminishes  the 
amount  of  blood  which  reaches  the  right  auricle,  and  consequently 
causes  the  pressure  in  that  chamber  to  fall  relatively  to  that  in 
the  left  auricle.  Moreover,  the  pressure  in  the  latter  chamber  is 
itself  greatly  increased  in  consequence  of  the  expansion  of  the 
capillaries  in  the  lungs,  which  takes  place  coincident  with  the 
establishment  of  pulmonary  respiration,  and  enables  a  greater 
quantity  of  blood  to  flow  into  the  auricle.  The  result  is  that  the 
flow  of  blood  through  the  foramen  ovale  is  stopped  by  the  closure 
of  the  valve  which  guards  it,  and  later  on  the  foramen  becomes 
entirely  occluded  by  the  formation  of  adhesions.  At  the  same 
time,  the  suction  of  the  blood  in  the  pulmonary  arteries  into  the 
lungs,  together  with  the  high  aortic  blood-pressure,  prevents  the 
passage  of  any  blood  through  the  ductus  arteriosus.  The  walls  of 
the  duct  in  consequence  come  in  contact  with  one  another,  and 


THE  FCETAL  DIGESTIVE  SYSTEM  103 

in  a  few  days  the  duct  is  completely  occluded  without  the  forma- 
tion of  thrombus.  It  closes  first  in  the  centre,  and  remains 
pervious  longer  at  the  aortic  than  at  the  pulmonary  extremity  in 
consequence  of  the  higher  pressure  at  the  aortic  end. 

The  hypogastric  arteries  and  the  umbilical  vein,  with  its  con- 
tinuation the  ductus  venosus,  also  become  obliterated  soon  after 
birth.  The  arteries  are  usually  closed  by  the  second  day,  the 
process  being  partly  effected  by  the  formation  of  thrombi  within 
them.  Great  thickening  of  the  fibrous  tissue  of  their  walls  also 
takes  place,  and  ultimately  reduces  them  to  the  condition  of 
fibrous  cords.  The  vein  remains  patent  till  a  slightly  later  date, 
but  is  usually  closed  by  the  seventh  or  eighth  day. 

The  Digestive  System. — Very  little  is  definitely  known  concern- 
ing the  activity  of  the  various  glands  connected  with  the  alimen- 
tary canal  in  the  foetus.  A  few  observations  have  been  made 
which  show  that  the  salivary  and  gastric  ferments  are  present  at 
birth,  and  according  to  some  at  a  much  earlier  period.  Trypsin 
also  is  stated  to  be  present  in  the  pancreatic  secretion  in  the 
second  half  of  pregnancy,  and  the  fat-splitting  ferment  is  in  most 
cases  present  at  birth.  The  amylopsin  of  the  pancreatic  secre- 
tion does  not,  however,  appear  till  some  time  after  birth. 

The  large  size  of  the  foetal  liver  has  caused  it  to  be  credited 
with  important  functions.  It  assumes  its  characteristic  structure 
at  about  the  fifth  month,  and  at  the  same  time  commences  to 
secrete  a  greenish-coloured  bile.  The  latter  collects  in  the  large 
intestine  and  forms  the  greater  part  of  the  meconium,  in  which 
bile-acids  and  bile-pigments  can  be  shown  to  exist.  It  also 
collects  in  the  gall-bladder,  which  is  sometimes  found  fully  dis- 
tended in  full-term  foetuses.  Before  the  secretion  of  bile  no 
meconium  is  found  in  the  intestines,  but  after  the  fifth  month  it 
collects  in  large  quantities.  Analysis  shows  that  it  contains,  in 
addition  to  the  bile-pigments  and  salts,  a  considerable  amount  of 
mucin,  and  secretions  from  the  various  intestinal  glands,  more 
especially  that  of  the  pancreas.  The  presence  of  lanugo,  vernix 
caseosa  and  epidermal  cells  within  it,  confirms  the  opinion  that 
the  liquor  amnii  is  swallowed  at  intervals  by  the  foetus.  In  cases 
of  occlusion  of  the  bile-ducts  the  meconium,  is  of  a  brownish 
colour.  In  addition  to  its  function  in  secreting  bile,  it  is  generally 
supposed  that  the  glycogenic  function  of  the  liver  is  early  estab- 
lished, and  that  its  large  size  is  correlated  with  the  presence  of 
large  amounts  of  sugar  in  the  tissues  of  the  foetus.  Some 
glycogen  can  be  detected  in  its  substance  at  birth. 

The  principal  waste  substances  which  result  from  the  nitro- 
genous metabolism  of  the  foetus  are  excreted  by  means  of  the 
placenta  into  the  maternal  circulation,  but  a  small  amount  of 
urea  and  uric  acid  is  also  passed  with  the  secretions  of  the  kidney 
into  the  bladder,  and  is  thence  probably  passed  at  intervals  into 
the  amniotic  fluid.  That  the  bladder  is  frequently  full  during 
intra-uterine  life  is  proved  by  the  familiar  fact  of  the  emptying  of 


104       OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 

that  viscus  which  so  often  takes  place  immediately  after  birth,  but, 
that  any  important  excretory  function  is  performed  by  the  kidneys 
before  birth  has  not  been  proved. 

The  Nervous  System. — The  various  parts  of  the  spinal  cord  and 
brain  are  only  gradually  developed,  and  at  birth  the  cortical  cells 
are  still  rudimentary,  so  that  it  is  probable  that  till  some  time 
after  birth  the  child  is  neither  capable  of  receiving  painful  sensa- 
tions nor  of  exerting  true  voluntary  movement.  Reflex  move- 
ments, however,  take  place  actively  in  utero,  and  can  readily  be 
excited  by  stimulation  of  the  abdomen  of  the  mother,  and  by 
various  other  means. 


THE   CHARACTERISTICS  OF  THE  FCETUS  AT  THE 
DIFFERENT  MONTHS 

First  Month. — Among  the  earliest  human  ova  which  have  been 
described  are  those  obtained  by  Peters  and  Leopold.*  The  latter 
was  supposed  to  be  about  ten  days  old,  and  the  former  still 
younger.  Reichert  has  also  described  an  ovum  of  about  twelve 
days  old.  In  none  of  these  was  any  definite  embryonic  area 
visible,  but  Leopold's  and  Reichert's  were  covered  with  primitive 
villi,  which  in  Reichert's  specimen  formed  a  definite  equatorial 
zone  around  the  greatest  circumference  of  the  vesicle.  In  Peters' 
specimen  of  six  days,  the  commencement  of  the  formation  of  villi 
could  be, detected.     By  the  end  of  the  second  week,  the  embryonic 


Fig.  74. — Early  Human  Ovum — from  fourteen  to  Twenty-one  Days 
Old  (Natural  Size). 

area  has  appeared,  and  the  embryo  measures  about  one-twelfth 
of  an  inch,  while  the  length  of  the  ovum  is  nearly  a  quarter  of  an 
inch.  By  the  end  of  the  third  week,  the  embryo  has  attained  a 
length  of  one-sixth  of  an  inch.  The  medullary  canal  is  formed, 
and  shows  the  differentiation  into  cerebral  vesicles  anteriorly, 
and  also  the  rudiments  of  the  visual  and  auditory  structures. 
The  visceral  arches  are  present,  and  the  stomatodaeum  is  well 
denned,  while  small  lateral  projections  represent  the  commence- 
ment of  formation  of  the  limbs.  The  amnion  is  fully  formed, 
and  the  vitelline  duct  is  commencing  to  narrow.  The  vitelline 
circulation  is  established,  and   the  allantois  is   in  contact  with 

*  Leopold,  'Verhandl.  d.  deutsch.  Gesell.  f.  Gyn.,'  1897.  Reichert, 
'  Beschreibung  einer  fruhzeit.  menschl.  Frucht.'  Peters,  '  Ueber  die 
Einbettung  des  menschl.  Eies,'  Wien,  1899. 


THE  CHARACTERISTICS  OF  THE  FCETUS  105 

the  deep  surface  of  the  chorion.  By  the  end  of  the  fourth 
week,  the  embryo  has  again  doubled  in  length.  The  various 
flexures  of  the  neural  canal  have  been  formed,  so  that  the  fore- 
brain  lies  in  front  of  the  fore-gut,  and  the  mid-brain  forms  a 
marked  dorsal  prominence.  The  heart,  which  appeared  towards 
the  end  of  the  second  week,  has  become  larger,  and  the  visceral 
arches  and  limbs  are  more  pronounced.  The  mouth  and  anus 
are  also  formed.  The  amnion  has  not  yet  come  into  contact  with 
the  chorion. 

Second  Month. — During  the  second  month,  the  embryo  increases 
more  gradually  in  size,  and  at  the  end  of  the  eighth  week  measures 
about  one  and  a  quarter  inches  in  length,  and  the  whole  ovum  is 
about  the  size  of  a  hen's  egg.  The  umbilical  vesicle  has  become 
small,  and  is  suspended  from  the  embryo  by  a  narrow  vitelline 
duct.  The  umbilical  cord  has  increased  in  length,  and  the  villi 
are  becoming  numerous  in  the  region  of  the  decidua  serotina. 
The  limbs,  after  the  fifth  week,  show  grooves  which  mark  them 
out  into  three  distinct  segments,  and  rudiments  of  the  fingers  and 
toes  have  also  appeared.  Centres  of  ossification  appear  early  in 
the  sixth  week  in  the  lower  jaw  and  in  the  clavicle.  At  the  end 
of  this  month  the  nose  begins  to  assume  its  normal  shape. 

Third  Month.  —  At  the  end  of  the  third  month,  the  foetus 
measures  from  three  to  three  and  a  quarter  inches  in  length, 
and  weighs  a  little  more  than  three  ounces.  The  placenta 
has  become  formed,  and  the  villi  over  the  rest  of  the  chorion 
have  almost  disappeared.  The  cord,  which  has  become  much 
elongated,  has  developed  its  spiral  twist,  and  is  inserted  much 
nearer  the  tail  than  the  head  end  of  the  embryo.  Nails  have 
appeared  as  thin  scales  on  the  fingers  and  toes,  and  centres  of 
ossification  are  present  in  most  of  the  bones.  The  head  is 
separated  from  the  trunk  by  means  of  the  neck,  and  the  mouth 
has  become  separated  from  the  nasal  cavities  by  the  development 
of  the  palate.  The  folds  which  form  the  labia  majora  and  scrotum 
are  present,  and  the  genital  eminence  is  beginning  to  assume  a 
characteristic  male  or  female  form. 

Fourth  Month. — At  the  end  of  the  fourth  month  the  fcetus  attains 
a  length  of  about  five  inches,  one  quarter  of  the  entire  length 
being  formed  by  the  head.  The  bones  of  the  skull  are  ossifying, 
but  are  still  separated  by  wide  sutures  and  fontanelles.  Fine 
downy  hair  has  appeared  on  the  scalp  and  over  some  other  parts 
of  the  body.  The  mouth  and  nose  have  assumed  their  normal 
shape  and  the  sex  is  now  easily  distinguishable.  The  Whartonian 
jelly  has  appeared  around  the  vessels  of  the  umbilical  cord,  and 
movements  of  the  limbs  have  just  commenced  to  take  place. 

Fifth  Month. — The  foetus  now  measures  about  ten  inches  in 
length  and  weighs  about  a  pound.  A  covering  of  fine  hair 
(lanugo)  covers  the  whole  body,  and  the  vernix  caseosa  has  made 
its  appearance.  This. latter  is  a  greasy  white  material  composed 
of  sodden  epidermis  and  sebum,  and  its  presence  prevents  imbi- 


106       OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 

bition  of  the  liquor  amnii  by  the  skin.  The  liver  has  assumed  its 
characteristic  histological  character,  and  meconium  is  found  in 
small  amounts  in  the  intestines.  The  head  is  still  relatively- 
large.  The  fcetal  movements  are  now  distinctly  perceptible  by 
the  mother. 

Sixth  Month. — At  the  end  of  the  sixth  month,  the  length  of  the 
foetus  is  about  twelve  inches  and  the  weight  about  two  pounds. 
The  skin  is  still  somewhat  wrinkled,  but  a  slight  deposition  of 
subcutaneous  fat  is  present.     The  eyelids  become  separated  and 


Four  Weeks 
Three 


Fig.  75. — Diagrammatic  Representation  of  Increase  of  Size  of 

fcetus  from  the  third  to  the  eighth  week.) 

(Enlarged  about  three  times.     After  Mall.) 

the  eyebrows  and  eyelashes  appear.     The  hair  on  the  head  is 
much  longer  than  on  the  rest  of  the  body. 

Seventh  Month. — The  average  length  is  now  about  fourteen 
inches,  and  the  average  weight  about  three  pounds.  In  males, 
the  testes  have  reached  the  inguinal  canals.  The  subcutaneous 
fat  has  increased  in  amount,  and  the  membrana  pupillaris  in 
front  of  the  lens  of  the  eye  is  very  conspicuous.     The  foetus  is 


THE  FULL-TERM  FCETUS  107 

generally  regarded  as  viable  at  the  end  of  the  seventh  month, 
but  many  born  alive  at  this  period  only  survive  for  a  few  hours. 
Rarely,  children  born  during  the  sixth  month  survive  by  the  use 
of  the  incubator,  but  such  survival  must  be  regarded  as  excep- 
tional. 

Eighth  Month. — The  average  length  at  the  end  of  the  eighth 
month  is  from  sixteen  to  seventeen  inches,  and  the  weight  is  from 
four  to  four  and  a  half  pounds.  The  wrinkling  of  the  skin  is 
almost  gone,  and  the  lanugo  is  commencing  to  disappear.  The 
pupillary  membrane  is  also  disappearing.  In  males,  the  testes 
are  usually  found  in  the  scrotum.  Children  born  at  this  period 
are  less  active  than  those  born  at  full  term,  but  can  sometimes 
be  reared  if  carefully  tended. 

Ninth  Month. — In  the  ninth  month,  growth  is  less  rapid,  and  the 
length  may  not  increase  more  than  an  inch  over  that  of  the  eighth 
month,  i.e.,  up  to  about  18  inches.  The  weight  is  from  \\  to 
5 1  lbs.  Adipose  tissue  is  now  present  in  abundance,  and  an 
ossific  centre  usually  appears  at  the  end  of  the  month  in  the 
epiphysis  at  the  lower  end  of  the  femur. 

Tenth  Month.— -The  characteristics  of  the  full-term  foetus  are  so 
important  that  they  will  be  discussed  at  greater  length  in  the 
following  sections. 


THE  FULL-TERM  FOETUS 

By  the  end  of  the  tenth  month,  the  marked  redness  of  pre- 
maturity is  toned  down,  and  the  skin  of  the  foetus  is  of  a  pale-red 
colour.  The  lanugo  has  almost  disappeared,  but  traces  may 
still  be  found  upon  the  neck,  shoulders,  and  back.  The  amount 
of  vernix  caseosa  which  covers  the  body  is  very  variable.  Some- 
times it  is  almost,  or  entirely,  absent ;  at  other  times,  the  infant 
is  so  covered  with  this  substance  that  but  little  skin  can  be 
seen.  The  origin  of  vernix  has  been  already  mentioned,  but 
we  do  not  know  of  any  attempts,  other  than  those  based  on 
popular  superstitions,  to  explain  the  marked  variations  which  are 
met  with  in  its  amount.  The  finger-nails  of  the  foetus  project 
well  beyond  the  finger-tips,  whilst  the  toe-nails  have  just  reached 
the  end  of  the  bed  of  the  nail.  The  hair  is  well  grown,  and  is 
about  an  inch  to  an  inch  and  a  half  in  length.  In  male  infants, 
the  testicles  have  descended  into  the  scrotum  ;  in  female  infants, 
the  labia  majora  project  beyond  and  cover  the  labia  minora. 
The  insertion  of  the  umbilical  cord  is  from  an  inch  to  ii  inches 
(2^  to  3  centimetres)  below  the  middle  point  of  the  body  (Winckel). 
If  the  infant  is  born  alive  and  is  healthy,  it  cries  vigorously,  and 
attempts  to  suck  anything  which  is  placed  between  its  lips. 

Weight  and  Length.  —  The  average  weight  of  the  full-term 
foetus  is  said  to  be  between  6  lbs.  9-8  oz.  and  7  lbs.  11  -45  oz. 
(3,000   to  3,500  grammes),  while   the  average  length  is  twenty 


108       OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 

inches  (48  to  54  centimetres).  Considerable  variations  in  the 
weight  are  commonly  met  with.  Infants  have  been  born  at  full 
term  who  did  not  exceed  4  lbs.  6-5  oz.  (2,000  grammes),  but  in 
such  cases  there  is  usually  some  foetal  or  maternal  pathological 
condition  which  has  interfered  with  development.  On  the  other 
hand,  cases  have  been  recorded  of  infants  who  weighed  13  lbs. 
3  oz.  (Mme.  Lachapelle),  15  lbs.  7  oz.  (Neumann),  17  lbs.  10  oz. 
(A.  Martin),  and  19  lbs.  13  oz.  (Cazeaux).  However,  any  weight 
exceeding  eleven  pounds  must  be  considered  as  very  exceptional. 
Various  factors  are  known  to  influence  the  weight  and  length 
of  a  foetus,  and  doubtless  there  are  many  more  which  have  not 
been  definitely  ascertained.  Ribemont-Dessaignes*  has  sum- 
marised the  opinions  of  various  authorities  on  the  known  factors 
as  follows  : — 

(1)  The  foetal  weight  increases  with  the  age  of  the  mother  until 
she  is  twenty-nine,  and  then  diminishes.  The  length  of  the  foetus 
increases  with  the  age  of  the  mother  up  to  forty-four  (Duncan). 

(2)  Repeated  pregnancies  tend  to  cause  an  increase  in  the 
weight  and  length  of  the  foetus  (Hecker,  Tarnier). 

(3)  Such  increase  in  weight  occurs  with  the  greater  regularity 
the  longer  are  the  intervals  between  each  successive  pregnancy 
(Wernich). 

(4)  In  successive  pregnancies,  when  a  male  infant  follows  a 
female  there  is  more  likely  to  be  an  increase  in  weight  than  when 
a  female  infant  follows  a  male  (Ribemont-Dessaignes).  This  is 
really  only  another  way  of  saying  that  a  male  infant,  as  a  rule, 
weighs  more  than  a  female. 

(5)  The  earlier  puberty  occurs  the  better  developed  will  be  the 
infant. 

The  influence  of  sex  and  multiparity  is  further  shown  by  the 
following  table  (Tarnier's) : — 


PRIMIPAR/K. 

Multipara. 

Male. 

Female. 

Male. 

Female. 

Average  weight  of 

placenta 
Average  weight  of 

child      

lb.  oz.   drm. 

1     2     9-4 
6  15   10 

lb.  oz.  drm. 
1     2   10-5 
6  13     6 

lb.  oz.  drm. 
1     3     5'2 

7     6     15 

!b.  oz.  drm. 
1     3     07 
6  14     0 

It  would  appear  from  this  table,  not  only  that  the  offspring  of  a 
multipara  is  heavier  than  that  of  a  primipara,  but  that  a  male 
infant  appears  to  be  better  able  to  take  advantage  of  the  extra 
nutriment  which  a  multipara  affords  than  is  a  female  infant. 

Precis  d'Obstetrique,'  par  A.  Ribemont-Dessaignes  et  G.  Lepage,  vol.  i. , 


p.  130. 


THE  FCETAL  SKULL 


109 


The  relations  which  exist  between  the  weight  of  the  infant  at 
birth  and  its  vitality  are  shown  by  the  following  table."  The 
weights  given  are  those  of  male  infants  ;  for  female  infants,  a 
slightly  smaller  weight  must  be  allowed  : — 


Weight  of  Infrint. 

Vitality. 

2,000  grammes  (4*  lb.  approx.) 
2,500       ,,         s\ 

3,000          ,,            6i 

3,500          ,,            7I 
4,000         ,,           8 
4.500          ,,            9 

Very  low 

Low 

Fair 

Normal 

High 

Very  high 

The  length  of  the  foetus  is  very  constant,  and  is  about  20  inches. 
It  may  vary,  however,  between  15!  and  24  inches. 

The  average  weights  of  the  different  organs  at  term  are  of 
importance,  as  they  are  sometimes  of  assistance  in  determining 
whether  a  dead  infant  has  reached  term  or  not.  The  following 
table  shows  the  weight  of  the  principal  viscera,  and  is  a  mean 
between  two  tables  which  have  been  published  by  Hecker  and 
Buhl  :—  I 


Viscu?. 

Weight. 

Right  lung 
Left  lung 

Heart      

Thymus  gland  ... 

Thyroid  gland  ... 

Liver 

Brain 

Spleen    ... 

Kidney  ... 

oz.     drm. 
1       0-93 
0     14-11 
0     10-51 

0       4-5!5 
0       2-822 
3     11-26 

12          IOig 

0       4\5J5 
0       6-208 

The  Foetal  Skull. — The  skull  of  the  foetus  is  the  most 
important  part,  from  the  point  of  view  of  the  mechanism  of 
labour,  as  it  furnishes  the  greatest  diameters  which  have  to  pass 
through  the  pelvic  cavity.  Accordingly,  a  clear  idea  of  its  shape, 
size,  and  compressibility  must  be  obtained  before  we  are  in  a 
position  to  deal  with  the  relative  importance  of  the  various  posi- 
tions which  the  foetus  can  assume.  This  can  best  be  obtained  by 
studying  the  general  characteristics  of  the  foetal  head,  its  sutures, 
fontanelles,  diameters,  and  circumferences,  and  by  mapping  it  out 
into  arbitrary  regions  which  will,  more  or  less,  correspond  with 

*   '  Pediatrics,'  by  Rotch,  p.  37. 

t  Ribemont-Dessaignes,  '  Precis  d'Obstetrique,'  vol.  i.,  p.  132. 


no       OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 

the  different  positions  in  which  the  head  may  pass  through  the 
pelvic  canal. 

General  Characteristics. — The  foetal  skull  is  composed  of  two 
parts — the  cranium  and  the  face.  The  cranium,  which  constitutes 
the  larger  portion  of  the  skull,  and  so,  from  an  obstetrical  point  of 
view,  is  the  more  important,  is  composed  of  eight  bones.  It  can 
be  subdivided  into  a  vault  and  a  base.  The  former  is  constituted 
by  the  lateral  halves  of  the  frontal  bone,  the  two  parietal  bones, 
the  squamous  portion  of  the  two  temporal  bones,  and  the  occipital 
portion  of  the  occipital  bone.  Its  most  important  characteristic, 
from  an  obstetrical  point  of  view,  is  to  be  found  in  the  fact  that 
these  bones,  instead  of  being  more  or  less  rigidly  united  to  one 
another,  are  only  connected  by  a  membranous  union.  The  result 
is  that  the  vault  of  the  cranium  is  essentially  compressible — a 
most  important  attribute  as  we  shall  presently  see.  The  mem- 
branous unions  between  the  various  bones  are  termed  sutures, 
and  the  meeting-place  of  two  or  more  sutures  is  termed  a  fon- 
tanelle.  The  base  of  the  skull,  on  the  other  hand,  is  an  incom- 
pressible structure,  whose  dimensions  cannot  be  altered  by  any 
force,  save  one  which  is  sufficient  to  bring  about  an  actual  rupture 
of  its  parts.  It  is  formed  by  the  following  bones — the  orbital  plates 
of  the  frontal  and  the  cribriform  plate  of  the  ethmoid,  the  body 
and  wings  of  the  sphenoid,  the  petrous  portion  of  the  temporal 
bones,  and  the  condylar  and  basilar  portions  of  the  occipital  bone. 

The  face,  owing  to  its  smaller  size,  is  of  comparative  unim- 
portance. It  is  composed  of  fourteen  bones,  which  are  so  united 
to  one  another  that,  like  the  base  of  the  cranium,  the  structure 
which  they  form  is  incompressible. 

Sutures.— As  has  been  said,  the  term  suture  (sutura,  a  stitch, 
hence,  a  union)  is  applied  to  the  lines  of  articulation  of  the  bones 
of  the  skull.  There  are,  however,  only  certain  sutures  which 
concern  the  obstetrician,  namely,  those  which  furnish  the  bones 
of  the  cranium  with  their  necessary  mobility  during  labour,  and 
with  these  alone  we  shall  deal.     These  sutures  are  as  follows  : 

(i)  The  sagittal,  or  interparietal  suture,  lying,  as  its  name  shows, 
between  the  parietal  bones. 

(2)  The  frontal  suture,  lying  between  the  lateral  halves  of  the 
frontal  bone. 

(3)  The  lambdoidal,  or  occipito-parietal  suture,  lying  between 
the  two  parietal  bones  and  the  occipital  bone. 

(4)  The  coronal,  or  fronto-parietal  suture,  lying  between  the 
parietal  bones  and  the  frontal  bone. 

(5)  The  two  squamous,  temporal,  or  temporo-parietal  sutures, 
lying  between  the  squamous  portion  of  the  temporal  bone  and 
the  frontal,  parietal,  and  occipital  bones,  at  each  side  of  the  skull. 

Looked  at  from  a  wider  standpoint  than  that  of  mere  relation 
to  different  bones,  we  see  that  these  sutures  fall  into  three  groups, 
and  that  each  of  these  groups  imparts  a  definite  range  of  move- 
ment to  the  vault  of  the  cranium  : — 


THE  FCETAL  SKULL  in 

A.  A  superior  longitudinal  group,  composed  of  the  frontal  and 
the  sagittal  sutures.  It  runs  from  near  the  glabella  (i.e.,  the  space 
between  the  superciliary  ridges,  and  immediately  above  the  trans- 
verse suture  of  union  of  the  frontal  with  the  nasal  and  superior 
maxillary  bones)  to  the  apex  of  the  occipital  bone. 

B.  An  inferior  longitudinal  group,  composed  of  the  squamous 
suture  and  half  of  the  lambdoidal  suture.  It  runs  at  each  side  of 
the  head  between  the  lower  and  outer  angle  of  the  frontal  bone 
and  the  apex  of  the  occipital  bone. 

C.  A  transverse  group,  consisting  of  the  coronal  suture  alone. 

As  a  result  of  the  presence  of  the  superior  and  inferior  longi- 
tudinal groups,  the  transverse  dimensions  of  the  vault  of  the 
cranium  can  be  diminished  by  pressure  applied  to  the  sides  of  the 
cranium.  As  a  result  of  the  lateral  group,  the  antero-posterior 
diameters  can  be  diminished  by  pressure  applied  to  the  fore  and 
hind  part  of  the  cranium.  It  is  accordingly  easy  to  see  that  the 
practical  importance  of  these  sutures  in  facilitating  the  mechanism 
of  labour  is  very  great. 

Fontanelles. — The  term  '  fontanelle  '  (diminutive  of  fons,  a  foun- 
tain) is  applied  to  the  space  which  exists  at  the  meeting  of  two 
or  more  sutures.  The  origin  of  the  term  is  probably  due  to  the 
resemblance  between  the  pulsations  transmitted  from  the  vessels 
of  the  brain  to  the  fontanelles  and  the  intermittent  bubbling  of 
a  spring.  The  fontanelles  are  six  in  number,  and  fall  naturally, 
into  two  groups,  according  to  their  relative  importance  : — 

(i)  The  Principal  Fontanelles. — These  are  single,  and  are  two  in 
number: — 

(a)  The  anterior  fontanelle,  or  the  bregma  (/3pexetv,  to  moisten), 
or  the  large  fontanelle,  is  situated  at  the  junction  of  the  frontal, 
the  coronal,  and  the  sagittal  sutures.  It  forms  a  lozenge-shaped 
opening  through  which  the  pulsations  of  the  vessels  of  the  brain 
are  transmitted.  When  the  bones  of  the  cranium  are  compressed, 
as  in  the  process  of  labour,  the  fontanelle  is  temporarily  oblite- 
rated, and  its  place  can  only  be  determined  by  noting  the  inter- 
section of  four  sutures.  The  term  '  bregma '  originated  in  the 
belief  that  the  top  of  the  head  was  humid  in  infants,  and  also 
that  it  corresponded  with  the  most  humid  part  of  the  brain. 

(b)  The  posterior  fontanelle,  or  the  small  fontanelle,  is  situated 
at  the  junction  of  the  sagittal  and  the  lambdoidal  sutures.  It  is 
triangular  in  form  and  considerably  smaller  than  the  anterior 
fontanelle.  During  labour,  compression  of  the  bones  of  the 
cranium  obliterates  it,  and  its  site  can  only  be  recognised  by  the 
fact  that  it  lies  at  the  intersection  of  three  sutures. 

(2)  The  Accessory  Fontanelles. — The  accessory  fontanelles  are 
double,  and  are  two  in  number  : — 

(a)  The  antero-lateral,  or  the  temporal  fontanelles,  are  situated, 
one  at  each  side,  at  the  junction  of  the  coronal  and  squamous 
sutures.  They  are  irregularly  shaped  apertures,  and  are  of  no 
very  great  practical  importance. 


H2        OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 

(b)  The  posterolateral,  or  mastoid  fontanelles,  are  situated,  one 
at  each  side,  at  the  junction  of  the  lambdoidal  and  squamous 
sutures.  They  are  also  of  irregular  shape  and  of  slight  im- 
portance.     .    . 

In  addition  to  the  assistance  which  the  fontanelles  give  to  the 
mechanism  of  labour  by  increasing  the  compressibility  of  the 
cranium,  they  also  constitute  important  diagnostic  landmarks 
(points  de  repere)  on  the  surface  of  the  skull.  The  method  by 
which  the  principal  fontanelles  can  be  distinguished  from  one 
another  has  been  mentioned,  and  it  only  remains  to  point  out 
a  possible  though  rare  source  of  error.  This  consists  in  the 
existence  of  adventitious  gaps  along  the  edges  of  the  parietal 
suture.  As  a  rule,  these  gaps  are  so  small  in  size  that  they  do 
not  give  rise  to  any  confusion,  if,  indeed,  their  existence  is  even 
detected.     Sometimes,  however,  it  so  happens  that  two  such  gaps 


Fig.  76. — The  Fcetal  Skull,  showing  Accessory  Fontanelle. 
(Ribemont-Dessaignes.) 

may  occur  opposite  one  another  along  the  course  of  the  suture 
and  may  then  constitute  a  close  imitation  of  a  fontanelle.  Such 
a  gap  is  shown  in  Fig.  76,  and  its  position  and  shape  show  how 
readily  it  might  have  been  confounded  with  the  anterior  fontanelle. 
Diameters. — The  diameters  of  the  foetal  skull  are  imaginary 
lines  drawn  through  the  skull  from  one  fixed  point  to  another, 
by  means  of  which  we  are  enabled  to  obtain  a  definite  idea  of 
the  size  and  shape  of  the  head.  The  various  diameters,  which 
are  usually  taken  into  consideration,  may  be  divided  into  two 
groups : — ■ 

A.  Antero-posterior  diameters. 

B.  Transverse  diameters. 

A.  Antero-posterior  Diameters. — Under  this  head  are  grouped, 
for  the  sake  of  convenience,  not  alone  all  diameters  which  actually 
run  antero-posteriorly,  but  all  those  which  lie  on  a  median-vertical 


THE  FCETAL  SKULL 


i'3 


plane  of  the  head.  If  we  start  from  the  junction  of  the  chin  and 
the  neck,  and  travel  round  the  head  to  a  point  below  the  occipital 
prominence,  we  shall  pass  one  by  one  the  various  points  from 


Fig.  77. — The  Fcetal  Skull  seen  from  the  Side,  showing  the  Points 
from  which  the  diameters  are  measured. 

A,  Junction  of  chin  and  neck  ;  B,  point  of  chin  ;  C,  glabella  ;  D,  most 
prominent  point  of  forehead  ;  E,  large  fontanelle ;  F,  most  distant  point 
on  sagittal  suture  ;  G,  small  fontanelle  ;  H,  lowest  point  on  occipital  bone. 

which  the  antero-posterior  diameters  start,  or  at  which  they  end. 
These  points  are  as  follows  : — ■ 

(a)  The  junction  of  the  chin  and  neck. 

(b)  The  tip  of  the  chin. 

(c)  The  glabella. 

(d)  The  most  prominent  part  of  the  frontal  bone. 

(e)  The  anterior  fontanelle. 

(/)  The  most  distant  point  on  the  sagittal  suture  from  the 

tip  of  the  chin. 
(g)  The  posterior  fontanelle. 
(h)  A    point    immediately   below    the    prominence  on    the 

occipital  bone. 
The  various  diameters  run  as  follows  from  these  points  : — 

(1)  One  diameter  starts  from  a  and  runs  to  e.  It  is  termed 
the  cervico-bregmatic,  or  tne  sub-mento-bregmatic  diameter,  and 
measures  3 -J  inches. 

(2)  Three  diameters  start  from  b,  and  run  respectively  to 
d,  f,  and  g.  They  are  known  as  the  fronto-mental  diameter, 
the     supra-occipito-mental    diameter,    and    the    occipito-mental 

8 


U4 


OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 


diameter.  The  supra-occipito-mental  diameter  is  the  longest 
diameter  of  the  head,  and  is  also  known  as  the  maximum 
diameter  of  Budin.  These  diameters  measure  respectively  3^,  5^, 
and  5  inches. 

(3)  One  diameter  starts  from  c  and  runs  to  g.  It  is  known  as 
the  occipito-frontal  diameter,  and  measures  \\  inches. 

(4)  Two  diameters  start  from  h  and  run  to  d  and  e  respectively. 
They  are  known  as  the  sub-occipito-frontal  diameter  and  the 
sub-occipito-bregmatic  diameter.  They  measure  respectively 
4  and  3f  inches. 


Fig.  78. — The  Fcetal  Skull  seen  from  the  Side,  showing  Diameters. 

AE,  Cervico-bregmatic  diameter;  BD,  fronto-mental  diameter;  BF,  supra- 
occipito-mental  diameter  ;  BG,  occipito-mental  diameter  ;  CG,  occipito- 
frontal diameter;  DH,  sub-occipito-frontal  diameter;  EH,  sub  occipito- 
bregmatic  diameter. 

B.  Transverse  Diameters. — The  transverse  diameters  of  the  head 
which  are  of  importance  are  two  in  number  : — 

(1)  A  diameter  running  between  the  parietal  eminences  and 
known  as  the  bi-parietal  diameter.     It  measures  3I  inches. 

(2)  A  diameter  running  between  the  extremities  of  the  coronal 
suture  and  known  as  the  bi-temporal  diameter.  It  measures 
3!  inches. 

It  must  be  remembered  that  the  length  of  all  these  diameters, 
save  the  bi-temporal,  can  be  altered  to  a  greater  or  less  extent  by 
compression. 

Circumferences. — The  relative  lengths  of  the  different  circum- 
ferences of  the  skull  are  of  importance.     The  head  during  labour 


THE  FCETAL  SKULL 


ii5 


has  to  pass  through  an   almost  rigid  canal,  and  this  can  only 
occur  when  it  assumes  such  a  position  that  the  greatest  circum- 


Fig.  79. — The  Fcetal  Skull  seen  from  in  Front. 
TT',  Bi-temporal  diameter. 

ference  which  has  to  pass  through  the  canal  is  neither  greater  in 
length  nor  possesses  diameters  which  are  greater  in  length  than 


Fig.  80. — The  Fcetal  Skull  seen  from  Behind. 
PP',  Bi-parietal  diameter. 

the  circumference  or  the  corresponding  diameters  of  the  canal 
through  which  it  has  to  pass.    The  following  are  the  four  circum- 

8—2 


n6        OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 

ferences  which  are  respectively  the  greatest  which  have  to  pass 
through  the  brim  in  the  different  degrees  of  flexion  or  extension 
in  which  the  head  may  lie  : — 

(i)  A  sub-occipito-bregmatic  circumference  measured  round 
the  ends  of  the  sub-occipito-bregmatic  diameter.  It  measures 
i2|-  inches,  and  its  maximum  diameters  are  the  sub-occipito- 
bregmatic  diameter  and  the  bi-parietal  diameter.  This  is  the 
maximum  circumference  of  the  head  which  has  to  pass  through 
the  brim  when  the  normal  degree  of  flexion  of  the  head  is 
present. 


Fig.  8i. — The  Fcetal  Skull  seen  from  Above. 
PP',  Bi-parietal  diameter. 

(2)  An  occipito-frontal  circumference  measured  round  the  ends 
of  the  occipito-frontal  diameter.  It  measures  13^  inches,  and  its 
maximum  diameters  are  the  occipito-frontal  and  the  bi-parietal. 
It  is  the  maximum  circumference  of  the  head  that  has  to  pass 
through  the  pelvis  when  the  head  is  in  a  position  midway  between 
flexion  and  extension. 

(3)  A  supra-occipito-mental  circumference — the  maximum  cir- 
cumference of  the  head — measured  round  the  ends  of  the  supra- 
occipito-mental  diameter.  It  measures  1 4^  inches,  and  its  greatest 
diameters  are  the  supra-occipito-mental  diameter  and  the  bi-parietal 
diameter.  It  is  the  maximum  circumference  of  the  head  which 
has  to  pass  through  the  pelvis  when  the  head  is  semi-extended. 


THE  FCETAL  SKULL 


117 


Fig.  82. — The  Circumferences  of  the  Fcetal  Skull  Measured  Round 
the  Different  Diameters. 

(From  tracings  of  the  head  of  a  newly-born  infant  made  by 
Dr.  R.  H.  Kennan.) 


n8       OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 


(4)  A  cervico-bregmatic  circumference  measured  round  the 
ends  of  the  cervico-bregmatic  diameter.  It  measures  i2-|  inches, 
and  its  maximum  diameters  are  the  cervico-bregmatic  and  the 
bi-parietal  diameters.  It  is  the  maximum  circumference  of  the 
head  which  has  to  pass  through  the  pelvis  when  the  head  is  fully 
extended. 

Just  as  the  diameters  of  the  head  can  be  altered  in  length  by 
compression,  so  the  circumferences  can  be  similarly  affected,  and 
can  all  be  more  or  less  reduced  in  length.  The  sub-occipito- 
bregmatic   circumference   can    perhaps    be    diminished    to    the 


Fig. 


-  The     Fcetal    Skull    seen    from    the    Side,    showing 
Different  Regions  into  which  it  is  mapped  out. 


greatest  extent  and  the  cervico-bregmatic  circumference  to  the 
least. 

Regions. — In  describing  the  antero-posterior  diameters  of  the 
skull  we  enumerated  eight  fixed  points  between  which  the  various 
diameters  ran.  We  shall  now  find  that  certain  of  these  points, 
as  well  as  being  the  termination  of  diameters,  are  also  natural 
landmarks  which  serve  the  purpose  of  mapping  out  the  head  into 
different  regions.     These  points  are  as  follows  ; — 

(1)  The  junction  of  the  chin  and  neck. 

(2)  The  glabella. 

(3)  The  anterior  fontanelle. 

(4)  The  posterior  fontanelle. 

(5)  The  point  on   the  occipital   bone  immediately  below 

the  occipital  prominence. 


THE  FCETAL  SKULL 


119 


The  parts  of  the  head  which  lie  between  these  points  constitute 
what  are  known  as  the  regions  of  the  head.  Between  the  junction 
of  the  chin  and  neck  and  the  glabella,  lies  the  face.  Between  the 
glabella  and  the  anterior  fontanelle,  lies  the  forehead  or  sinciput 
(a  corruption  of  semi,  half,  and  caput,  the  head).  Between  the 
anterior  and  posterior  fontanelles,  lies  the  vertex.  Between  the 
posterior  fontanelle  and  the  fixed  point  immediately  below  the 
prominence  of  the  occipital  bone,  lies  the  occiput. 


Fig. 


-The  Fcetal  Ovoid  seen  from  in  Front. 


VP,  Vertico-podalic  diameter;  AA',  bis-acromial  diameter;  TT'r  bi- 
trochanteric  diameter. 


The  lateral  boundaries  of  these  regions  are  variously  stated  by 
different  writers.  It  will  perhaps  be  best  to  consider  that  the 
face  is  bounded  laterally  by  a  vertical  line  drawn  down  imme- 
diately in  front  of  the  ears ;  that  the  sinciput  is  coterminous 
with  the  frontal  bone  ;  that  the  vertex  is  bounded  laterally  by  the 
prominences  of  the  parietal  bones  ;  and  that  the  occiput  is  coter- 
minous with  the  occipital  bone.  It  will  be  found  later  that  these 
regions  have  an  intimate  connection  with  the  different  presenta- 
tions of  the  head. 


120        OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 

The  Foetal  Trunk. — The  dimensions  of  the  foetal  trunk  are 
of  secondary  importance  to  those  of  the  skull,  inasmuch  as  they 
can  be  so  reduced  by  compression  during  labour  that"  normally 
they  do  not  interfere  with  the  passage  of  the  foetus.  The  distance 
between  the  tips  of  the  acromion  processes  of  the  scapula,  or  the 
bis-acromial  diameter,  is  the  greatest  transverse  diameter  of  the 
trunk,  and  measures  4-f  inches  (11  cms.).  It  can  be  reduced  by 
pressure  to  3§  inches  (8-5  cms.).  The  greatest  antero-posterior 
diameter  of  the  trunk,  or  the  sterno-dorsal  diameter,  lies  between 


Fig.  85. — The  Fcetus  seen  from  the  Side. 
DS,  Dorso- sternal  diameter. 


the  sternum  and  the  spinal  column,  and  measures  3I  inches 
(9-5  cms.).     It  can  be  reduced  by  pressure  to  3^  inches  (8  cms.). 

The  Fcetal  Breech. — The  dimensions  of  the  breech  are,  like 
those  of  the  trunk,  of  no  very  great  practical  importance.  Three 
diameters  are  usually  described  : — 

(1)  The  bi-trochanteric  diameter,  running  between  the  tro- 
chanters and  measuring  3|  inches  (9-5  cms.),  is  the  largest 
diameter. 


THE  MEASUREMENTS  OF  THE  FCETUS  12 1 

(2)  The  bis-iliac  diameter,  running  between  the  most  distantly 
separated  points  on  the  iliac  crests  and  measuring  3;.;  inches 
(9  cms.). 

(3)  The  sacro  -  iliac  or  antero  -  posterior  diameter,  running 
between  the  symphysis  and  the  sacrum,  and  measuring 
i\   inches  (5-5  cms.). 

The  following  table,  which  shows  the  different  measurements 
of  the  foetus,  may  be  of  use  for  reference  purposes  : — 

Diameters. 


Diameters. 

Inches. 

Centi- 
metres. 

i 

fCervico-bregmatic      ... 

3f 

9"  5 

Fronto-mental 

34 

8 

Supra-occipito-mental 

54 

H 

Occipito-mental 

5 

12-5 

Skull    1 

posterior 

Occipito-frontal 

\\' 

"'5 

Sub-occipito-frontal    ... 

4 

10 

l,Sub-occipito-bregmatic 

3f 

9*5 

Trans- 

"Bi-parietal 

3! 

9'5 

\     verse 

^Bi-temporal 

34 

8 

Trunk 

fBis-acromial    ... 
[Dorso-sternal  ... 

44 
34 

12 
9*5 

'Bi-trochanteric 

3l 

9 

Breech 

Bis-iliac 

34 

8 

^Sacro  iliac 

2i 

5*5 

Total  length 

20 

50 

Circumferences. 


Circumferences. 

Inches. 

Centimetres. 

Sub-occipito-bregmatic    ... 
Occipito-frontal    ... 
Supra-occipito-mental 
Cervico-bregmatic 

I2i 
I3l 

x4l 
12A 

32 
34 
36 
32 

122       OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 


THE    RELATIONS    OF    THE    FCETUS    TO    THE 
UTERUS 

The  relations  of  the  foetus  to  the  uterus  and  of  the  various 
parts  of  the  foetus  to  one  another  are  expressed  by  four  terms — 
attitude,  lie,  presentation,  and  position.  The  term  '  lie  '  is  not 
adopted  by  all  writers  on  obstetrics.  Its  use,  however,  carries 
with  it  certain  advantages  to  which  we  shall  presently  refer. 

Attitude. — The  term  '  attitude '  is  used  to  imply  the  relations 
which  exist  between  the  foetal  limbs  and  head  and  the  body  of 
the  foetus.  The  normal  attitude  of  the  foetus  in  the  later  months 
of  pregnancy  is  what  may  be  termed  one  of  universal  flexion. 
The  head  is  flexed  on  the  chest ;  the  spine  is  slightly  flexed  for- 
wards ;  the  arms  are  crossed  over  the  chest,  the  forearms  being 
flexed  on  the  upper  arms  ;  and  the  thighs  are  flexed  on  the 
abdomen  and  the  lower  legs  on  the  thighs.  One  result  of  this 
attitude  is  that  the  foetus  assumes  the  form  of  an  ovoid ;  that  is 
to  say,  the  most  compact  form  which  is  possible  for  it  to  assume 
and  the  one  which  is  best  suited  to  the  shape  of  the  investing 
uterus.  Another  result  is  that  the  foetus  in  its  passage  through 
the  genital  canal  offers  the  minimum  of  resistance  to  the  obstruc- 
tions which  it  has  to  overcome. 

The  average  dimensions  of  the  ovoid  which  the  foetus  thus 
forms  are  as  follows  : — ■ 

Diameter.  Inches.  Centimetres. 

Vertico-podalic  ...  ...  ...  ...         9^  to  10  24-25 

Bis-acromial  ...  ...  ...  ...         4*  12 

Bi-trochanteric  ...  ...  ...  ...         3*  9 

Dorso-sternal  ...  ...  ...  ...         3*  9*5 

All  these  diameters  can  be  more  or  less  reduced  by  com- 
pression. 

Dakin  considers  it  advisable  to  regard  the  foetal  body  as  being 
made  up  of  two  irregular  ovoids — the  head  and  the  trunk. 
Normally  the  axes  of  these  lie  parallel,  or  nearly  so,  to  one 
another,  and  so  they  form  component  parts  of  a  larger  ovoid. 
In  certain  cases  the  smaller  ovoid — namely,  the  head — does  not 
preserve  this  relationship  to  the  larger  ovoid,  and  as  a  result  an 
abnormal  attitude  is  produced. 

The  cause  of  the  normal  attitude  of  the  foetus  may  in  general 
terms  be  stated  to  be  the  necessity  for  adaptation  between  the 
shape  of  the  foetus  and  the  shape  of  the  uterus.  In  the  early 
months  of  pregnancy  the  foetus  does  not  fill  the  uterine  cavity, 
and,  consequently,  there  is  little  or  no  restraint  on  the  attitudes 
which  it  may  assume.  As,  however,  the  foetus  grows  and  comes 
to  fill  the  uterine  cavity  more  and  more  completely,  it  finds  itself 
subject  to  the  passive  control  of  the  uterine  walls.  The  result  of 
this  gentle  but  ever-increasing  pressure  is  that  the  foetus  is  com- 
pelled to  bring  the  attitude  of  its  head  and  limbs  into  conformity 


THE  ATTITUDE  OF  THE  FCETUS 


123 


w  g 

x  0 

H    « 

In 

w 

W    W 

0 

- — * 

D   in 

s 

H      - 

e 

•ajjlffl 


H 

1 

tn 

z 
0 

| 

P 

« 

0 

H  to 

co 

0 

to 

z 

-^f^j^" 


p 

W 

H 

Q 

C 

<Tl 

to 

H 

u 

K 

X 

H 

H 

[i 

s 

O 

0 

h 

w 

p 

Z 

H 

W 

w 

<1  tn 


a    - 

.-% 

H  2 

E 

I* 

£ 

i>- 

0 

00  s 

PQ 

6 

to 

w  § 

X   O 

H    « 

h 

O  z 
0  W 

w 

w  w 

0  tn 

E 

E 

6 


124        OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 

with  the  available  space.  The  pressure  of  the  uterine  walls 
acting  upon  the  head  brings  about  an  attitude  of  flexion,  and  the 
same  pressure  exerted  upon  the  limbs  tends  to  keep  them  approxi- 
mated to  the  trunk  of  the  foetus.  It  will  subsequently  be  seen 
that  the  necessity  for  accommodation  is  also  largely  responsible 
for  the  normal  lie  of  the  foetus. 


. — The  Full-term  Fcetds  in  the  Uterus. 


Note  the  correspondence  between  the  ovoid  shape  of  the  uterus  and 
that  of  the  foetus. 

Abnormal  attitudes  of  the  foetus  are,  speaking  generally,  any 
variation  from  the  attitude  which  we  have  described  as  normal. 
They  may  consist  in  any  abnormal  attitude  of  the  head,  as  has 
been  mentioned,  or  in  an  abnormal  attitude  of  the  limbs.  The 
correct  attitude  of  the  head  is  one  of  flexion  on  the  chest,  and  the 
most  common  variations  from  this  are  extension — either  complete 


THE  PRESENTATION  OF  THE  FCETUS  125 

or  partial — and  excessive  flexion.  The  most  common  variations  in 
the  normal  attitude  of  the  upper  limbs  are  extension  of  one  or 
both  arms  upwards,  beside  or  behind  the  head  ;  downwards, 
beside  or  behind  the  trunk  ;  and  outwards,  away  from  the  body. 
The  most  common  variations  of  the  attitudes  of  the  lower  limbs 
are  extension  of  one  or  both  thighs,  accompanied  or  not  by  a 
corresponding  extension  of  one  or  both  legs,  and  extension  of  one 
or  both  lower  legs  unaccompanied  by  extension  of  the  thighs. 
The  various  attitudes  may  be  tabulated  as  follows : — 


Normal  Universal  flexion 

f  Comp 

lplete 


! r\c  -t     j  f  Excessive  flexion    rr*         ,  , 

[Of  Head  l  Extension  /Complete 

I  extension  ^Incomp 


A  bnormal 


[Extension 
I  01 


Of  Upper  Limbs   ',  of  one  or 
[both  arms 


Upwards  |,    ,  .    ,  >  the  head 

Downwards  -! ,    ,  •    ■,  \  the  trunk 
k  Away  from  body 


{Extension  of  one  /with       ^  extension  of  one 
or  both  thighs     ^  without/     or  both  legs 
Extension  of  one  or  both  legs 

Lie. — By  the  term  'lie'  is  meant  the  relation  of  the  long  axis  of 
the  foetus  to  the  uterus.  When  the  long  axis  of  the  foetus  corre- 
sponds with  the  vertical  axis  of  the  uterus,  the  lie  is  said  to  be 
longitudinal.  When  it  corresponds  more  or  less  closely  with  the 
horizontal  axis  of  the  uterus,  it  is  said  to  be  transverse  or  oblique. 
A  longitudinal  lie  of  the  foetus  is  the  normal  lie,  and  the  pro- 
portion of  cases  in  which  it  occurs  is  overwhelmingly  greater 
than  the  proportion  in  which  a  transverse  lie  occurs.  In  100  cases 
of  labour  the  foetus  lies  longitudinally  in  90/44  per  cent.,  leaving 
the  small  proportion  of  0*56  per  cent,  for  transverse  lies.  The 
cause  of  the  almost  universal  occurrence  of  a  longitudinal  lie  is 
very  obvious.  As  we  have  already  seen,  the  long  axis  of  the 
foetal  ovoid  is  the  vertico-podalic  axis,  while  the  long  axis  of  the 
uterine  ovoid  is  the  vertical  axis.  The  relations  of  the  dimensions 
of  the  uterine  ovoid  to  those  of  the  foetal  ovoid  are  such,  that 
while  there  is  ample  room  for  the  foetal  ovoid  when  its  long  axis 
corresponds  with  the  long  axis  of  the  uterus,  there  is  insufficient 
room  for  it  to  lie  in  any  other  position.  Consequently,  as  soon  as 
the  foetus  becomes  of  sufficient  size  to  fill  the  uterine  cavity,  and 
so  to  be  pressed  upon  by  the  uterine  walls,  it  is  guided  round  by 
this  pressure  until  its  long  axis  corresponds  with  the  long  axis  of 
the  uterus,  or,  in  other  words,  until  its  lie  is  longitudinal.  If, 
however,  there  is  marked  alteration  in  the  shape  of  the  uterine 
cavity  or  of  the  foetus,  by  which  either  of  them  lose  its  ovoid 
character,  a  transverse  or  oblique  lie  may  result. 

Presentation. — The  presentation  is  the  term  applied  to  that  part 
of  the  foetus  which  has  engaged,  or  is  tending  to  become  engaged, 


126       OBSTETRICAL  ANATOMY —MATERNAL  AND  OVULAR 

in  the  pelvic  cavity,  or,  in  other  words,  it  is  that  part  of  the  foetus 
which  is  first  reached  by  the  finger  when  making  a  vaginal  ex- 
amination. 

The  different  presentations  can  be  divided  into  three  main 
groups : — 

A.  Cephalic  presentations,  or  presentations  of  the  head. 

B.  Pelvic  presentations,  or  presentations  of  the  breech  and 
lower  limbs. 

C.  Shoulder  presentations,  or  presentations  of  the  trunk  or 
upper  limbs. 

A  cephalic  or  a  pelvic  presentation  occurs  when  the  lie  is  longi- 
tudinal, a  shoulder  presentation  when  the  lie  is  transverse.  The 
latter,  therefore,  is  a  very  rare  occurrence.  Cephalic  presentations 
occur  in  a  very  much  larger  proportion  of  cases  than  do  pelvic 
presentations.  In  g6-88  per  cent,  of  all  cases  in  which  the  lie  is 
longitudinal,  the  head  presents,  while  a  pelvic  presentation  only 


Fig.  90. — Diagram  of  the  Fcetus  in 
utero  in   the  Early  Months. 


Fig.  91. — Diagram  to  show  Re- 
straining Effect  of  the  Shape 
of  the  Uterus  on  the  Position 
of  the  Fcetus  in  a  Longi- 
tudinal Lie, 


occurs  in  the  remaining  3-12  per  cent.  There  must  be  very 
definite  causes  for  such  a  preponderance  of  one  group  of  pre- 
sentations over  another,  and  these  causes  we  now  propose  to 
discuss. 

In  all  probability  the  preponderance  of  cephalic  presentations 
is  due,  not  to  one,  but  to  several  factors.  The  most  commonly 
recognised  of  these  are  as  follows  : — 

(1)  The  relation  between  the  shape  of  the  fcetus  and  the 

shape  of  the  uterus. 

(2)  The  effect  of  gravity  on  the  fcetus. 

(3)  The  movements  of  the  fcetus. 

(1)  The  Relation  between  the  Shape  of  the  Fcetus  and  the  Shape  of  the 
Uterus. — As  has  been  already  stated,  the  shape  of  the  uterine 


THE  PRESENTATION  OF  THE  FOETUS  127 

cavity  and  the  controlling  pressure  exerted  by  its  walls  have  a 
causal  effect  upon  the  attitude  and  lie  of  the  foetus  ;  we  shall  now 
see  that  they  have  a  similar  effect  upon  its  presentation.  The 
fcetus,  when  in  its  normal  attitude,  has  an  ovoid  form.  The  larger 
end  of  this  ovoid  is  composed  of  the  breech  and  lower  limbs,  the 
smaller  end  of  the  head.  The  uterine  cavity  is  also  of  an  ovoid 
shape  ;  the  fundus  constitutes  the  larger  end  of  the  ovoid,  the 
lower  portion  of  the  uterus  the  smaller  end.  It  is  thus  at  once 
obvious  that  if  the  fcetus  is  to  take  advantage  of  the  close  corre- 
spondence which  exists  between  its  shape  and  that  of  the  uterus, 
and  so  obtain  the  maximum  amount  of  room,  it  must  lie  longi- 
tudinally with  the  larger  end  of  its  ovoid  in  the  larger  end  of  the 
uterine  ovoid — that  is  to  say,  the  head  must  present.  In  this 
presentation,  the  fcetus  is  uniformly  pressed  upon  by  the  uterine 
walls,  while  in  any  other  presentation  the  pressure  varies  over  the 
different  parts  of  its  body.  Consequently,  the  passive  control  of  the 
uterus  tends  to  keep  the  fcetus  in  a  cephalic  presentation,  if  such 
already  exists,  whilst  it  tends  to  change  any  other  presentation  into 
a  cephalic  presentation.  If  there  is  any  alteration  in  the  normal 
form  of  the  fcetal  or  the  uterine  ovoid,  then,  although  accom- 
modation still  exists,  it  produces  different  consequences.  If  the 
cephalic  pole  of  the  fcetus  is  larger  than  the  podalic  pole,  the 
former  is  usually  found  at  the  fundus.  If  the  fundal  pole  of  the 
uterine  cavity  is  diminished  in  size,  or  if  the  pelvic  pole  is  in- 
creased in  size,  the  larger  pole  of  the  fcetus  will  usually  be  found 
occupying  the  latter. 

(2)  The  Effect  of  Gravity  on  the  Fcetus. — It  has  been  determined 
experimentally  that  the  centre  of  gravity  of  the  full-term  fcetus  is 
situated  about  the  level  of  the  shoulders,  nearer  the  right  shoulder 
than  the  left,  and  nearer  the  posterior  surface  of  the  fcetus  than 
the  anterior  (Mathews  Duncan).  As  a  result  of  this,  if  the 
fcetus  is  completely  immersed  in  a  fluid  of  the  same  specific 
gravity  as  the  liquor  amnii,  it  floats  on  its  back,  its  head  lower 
than  its  breech,  and  its  right  shoulder  slightly  lower  than  its  left. 
It  is  obvious,  then,  that  so  long  as  the  fcetus  is  free  to  move  in 
the  uterus,  it  will  lie  with  its  cephalic  pole  lower  than  its  podalic 
pole,  and  so  favour  the  occurrence  of  cephalic  presentations. 

(3)  The  Movements  of  the  Fcetus. — The  movement  of  the  fcetus, 
and  especially  the  movements  of  the  lower  limbs,  are  often 
sufficiently  strong  to  cause  an  alteration  in  the  presentation. 
This  alteration  is  most  prone  to  occur  when  the  fcetus  lies  in  such 
a  manner  that  its  lower  limbs  can  press  against  the  rigid  walls  of 
the  pelvis.  Active  movements  on  the  part  of  the  fcetus  will  then 
tend  to  push  the  podalic  pole  away  from  the  pelvic  brim,  and 
towards  the  fundus.  When  the  movements  cease,  the  podalic 
pole  may  again  return  to  its  former  situation,  only  to  be  again 
pushed  away  by  a  recurrence  of  the  movements.  If,  however, 
the  movements,  helped  by  the  other  factors  which  have  been 
mentioned,  are  sufficiently  strong  to  bring  the  podalic  pole  into 


128        OBSTETRICAL  ANATOMY—MATERNAL  AND  OVULAR 

the  fundus  of  the  uterus,  then  the  resistance  to  foetal  movements 
is  almost  completely  lost,  and  the  tendency  to  a  change  of  pre- 
sentation ceases,  as  a  flaccid  uterus  provides  no  resistance 
to  the  movements  of  the  limbs,  and  a  contracted  uterus,  by 
accentuating  the  ovoid  shape  of  the  uterus,  effectually  maintains  a 
cephalic  presentation. 

Other  theories  as  to  the  causation  of  cephalic  presentations  have 
been  brought  forward  from  time  to  time.  They  are  not,  how- 
ever, of  sufficient  importance  to  render  it  necessary  to  call  atten- 
tion to  them.  The  three  factors  which  we  have  mentioned  are  in 
all  probability  the  associated  causes  of  cephalic  presentations,  and 
may  be  said  to  jointly  act  as  follows.  In  the  early  months  of 
pregnancy,  the  foetus  is  subject  to  but  little  restraint  by  the  uterine 
walls,  and  consequently  it  lies  as  is  determined  by  gravity.  As 
the  head  increases  in  size,  and  the  centre  of  gravity  approaches 
the  shoulders,  the  presentation  tends  to  become  cephalic.  As  the 
lower  pole  of  the  foetus  grows,  and  the  ovoid  form  is  accentuated 


Fig.  92. — Diagram   to  show  Effect   of   Fcetal  Movements   in   causing 
Head  Presentation. 


owing  to  the  foetus  assuming  its  normal  attitude,  the  effect  of  the 
shape  of  the  uterus  begins  to  manifest  itself,  and  the  foetus  is 
found  in  a  longitudinal  lie.  If  the  presentation  is  cephalic,  the 
tendency  of  the  factors  enumerated  is  to  cause  it  to  persist.  If, 
on  the  other  hand,  the  presentation  is  pelvic,  the  tendency  of 
these  factors  is  to  bring  the  head  down  and  the  podalic  pole 
upwards.  Sooner  or  later  this  change  occurs,  and  once  it  has 
occurred  a  cephalic  presentation  persists. 

The  different  presentations,  which  are  grouped  under  the  in- 
clusive term  '  cephalic  '  presentation,  are  five  in  number,  and  are 
directly  due  to.  variations  in  the  attitude  of  the  head  of  the  foetus. 
If  the  foetus  preserves  its  normal  attitude  the  vertex  presents.  If 
the  head  is  more  flexed  than  normally,  the  posterior  fontanelle 
presents.  If  the  head  is  midway  between  flexion  and  extension, 
the  anterior  fontanelle  presents.  If  there  is  a  slight  degree  of 
extension  present,  the  sinciput  or  brow  presents.  While,  if  the 
head  is  fully  extended,  the  face  presents.     Two  more  presentations 


THE  PRESENTATION  OF  THE  FOETUS  129 

are  sometimes  added  to  this  list — anterior  and  posterior  parietal 
presentations.  We  have,  however,  come  to  the  conclusion  that 
to  do  so  unnecessarily  complicates  the  list  of  presentations,  inas- 
much as  it  adds  presentations  which  are  the  result,  not  of  flexion 
or  of  extension,  but  of  lateral  deviations  of  the  head.  Further, 
whereas  the  presence  of  one  of  the  foregoing  presentations 
excludes  the  presence  of  any  other,  if  we  add  parietal  presenta- 
tions to  the  list,  we  have  to  admit  that  two  presentations  can 
occur  at  the  same  time.  For,  if  in  a  vertex  presentation  the  head 
is  deviated  towards  one  or  other  shoulder,  a  parietal  presentation 
is  also  present.  This  is  apt  to  lead  to  confusion,  and  conse- 
quently we  prefer  to  refer  to  cases  of  lateral  deviation  of  the  head 
as  obliquities  of  the  head,  and  not  as  parietal  presentations. 

Under  the  inclusive  term  'pelvic  presentation,'  two  presentations 
are  included,  and  these  again  are  the  result  of  variations  in  the 
attitude  of  the  foetus. 

If  the  attitude  is  normal,  a  complete  pelvic  presentation  will 
result.  If  the  limbs  depart  from  their  normal  attitude,  an  incom- 
plete pelvic  presentation  will  result,  and  the  breech  alone,  one  or 
both  knees,  one  or  both  feet,  or  a  foot  and  a  knee,  may  be  found 
presenting,  according  to  the  variation  in  the  normal  attitude  which 
exists. 

In  longitudinal  lies,  the  exact  presentation  of  the  foetus,  par- 
ticularly when  it  is  cephalic,  is  of  the  utmost  importance.  If  the 
vertex  presents,  it  is  certain  that  labour  will  be  as  favourable  as 
the  other  circumstances  of  the  case  permit.  If,  on  the  other  hand, 
the  face  presents,  the  presumption  is  that  labour  will  not  be 
favourable  either  for  the  mother  or  the  foetus.  While,  if  the  brow 
or  sinciput  presents,  it  is  certain  that  labour  will  be  unfavourable 
for  both  mother  and  foetus,  unless  other  circumstances,  such  as  an 
exceptionally  roomy  pelvis,  facilitate  the  passage  of  the  large 
diameters  of  the  head.  In  transverse  lies,  on  the  other  hand,  the 
exact  presentation  is  not  of  any  very  great  importance,  since  it  is 
overshadowed  by  the  general  fact  that  there  is  no  presentation  in 
this  lie  in  which  the  foetus  can  be  delivered  under  otherwise 
normal  circumstances.  If  the  attitude  of  the  foetus  is  normal, 
the  shoulder  almost  invariably  presents.  If  the  normal  attitude 
is  lost,  an  elbow,  a  hand,  the  ribs,  or  perhaps  one  or  both  hands 
and  feet  may  present.  We  shall  not  consider,  therefore,  these  as 
separate  entities,  but  group  them  under  the  general  heading 
'  transverse  lie,'  or  '  shoulder  presentation.' 

The  following  is  a  list  of  the  different  presentations,  their 
frequency,  and  the  attitude  of  the  foetus  which  causes  them  : — 

Cephalic  Presentations. 

1.  Vertex  Presentation. — In  this,  the  head  is  in  its  normal  attitude 
of  flexion,  and  as  a  result  the  vertex  lies  lowest.  It  occurs  in 
almost  95*53  per  cent,  of  all  cases. 

9 


130        OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 

2.  Face  Presentation. — In  this,  the  attitude  of  the  head  is  one  of 
complete  extension,  with  the  result  that  the  face  lies  lowest.  It 
occurs  in  o-6  per  cent,  of  all  cases. 

3.  Brow  or  Sinciput  Presentation. — In  this,  the  head  is  slightly 
extended,  with  the  result  that  the  forehead  lies  lowest.  It  occurs 
in  0-2  per  cent,  of  all  cases. 

4.  Anterior  Fontanelle  Presentation. — In  this,  the  head  is  midway 
between  flexion  and  extension,  with  the  result  that  the  anterior 
fontanelle  lies  lowest.  The  proportion  of  cases  in  which  this  and 
the  following  presentation  occur  is  so  small  that  no  reliable 
statistics  of  their  frequency  can  be  given.  They  are  included  in 
the  percentage  of  vertex  presentations. 

5.  Posterior  Fontanelle  Presentation. — In  this,  the  head  is  more 
than  normally  flexed,  and,  consequently,  the  posterior  fontanelle 
lies  lowest.  If  flexion  is  still  more  exaggerated,  the  occiput  may 
present,  a  condition  termed  by  some  an  occipital  presentation. 


Pelvic  Presentations. 

1.  Complete  Pelvic  Presentation. — In  this,  the  foetus  lies  in  its 
normal  attitude,  and  as  a  result  the  breech  and  feet  present.  It 
is  difficult  to  ascertain  the  exact  proportion  of  cases  in  which  this 
presentation  occurs,  as  in  most  statistics  all  cases  of  pelvic  pre- 
sentation are  classified  together,  and  amount  to  3-1 1  per  cent,  of 
all  cases. 

2.  Incomplete  Pelvic  Presentation. — In  this,  the  normal  attitude  of 
the  foetus  is  altered,  with  the  result  that  three  sub-presentations 
are  found  : — 

(a)  The  thighs  are  flexed  and  the  lower'  legs  are  extended  and 
lie  along  the  trunk  of  the  foetus,  with  the  result  that  the  breech 
alone  presents — breech  presentation  proper. 

(b)  One  or  both  thighs  are  extended,  the  legs  remaining 
flexed,  with  the  result  that  one  or  both  knees  present — knee 
presentation. 

(c)  One  or  both  thighs  and  legs  are  extended,  with  the  result 
that  one  or  both  feet  present — footling  presentation. 

1 

Shoulder  Presentation. 

As  has  been  already  mentioned,  the  practical  importance  of  the 
exact  presentation  in  transverse  lie  is  not  great.  By  far  the 
commonest  presentation  is  a  shoulder.  It  occurs  in  0*56  per  cent, 
of  all  cases. 

It  is  quite  possible  that  objection  may  be  taken  to  the  inclusion 
of  fontanelle  presentations  in  the  list  of  cephalic  presentations,  on 
the  ground  that  they  are  only  the  result  of  slight  secondary 
changes  in  a  vertex   presentation.     All   presentations,  however, 


THE  PRESENTATION  OF  THE  FOETUS 


131 


may  be  divided  into  primary,  and  secondary  or  resultant.  Where 
there  is  no  deformity  of  either  the  uterus  or  the  fcetus,  there  is 
only  one  primary  presentation  of  the  head — i.e.,  a  vertex  pre- 
sentation, and  any  other  presentation  occurring  before  labour  has 
commenced  is  the  result  of  deformity.  Consequently,  all  the 
other  head  presentations  must  be  regarded  as  secondary  pre- 
sentations resulting  from  some  interference  with  the  mechanism 
of  labour.  The  exact  secondary  presentation,  which  results, 
depends  on  the  form  and  the  degree  of  this  interference,  and  its 
importance  must  be  estimated,  not  by  the  extent  of  the  displace- 
ment of  the  head  which  occurs,  but  by  the  nature  of  the  probable 
causal  agents  of  the  displacement,  and  by  the  length  of  the 
diameters  of  the  head  which  have  to  pass  through  the  pelvis. 
For  example,  a  brow  presentation  is  the  result  of  a  less  degree  of 
displacement  of  the  head  than  is  a  face  presentation,  but  it  is  a  far 
more  important  condition,  as  it  brings  into  the  brim  of  the  pelvis 


Fig.  93. — Diagram  of  Vertex  Pre- 
sentation. 


Fig. 


94. 


-Diagram  of  Face  Pre- 
sentation. 


diameters  which  are  frequently  too  large  to  pass  through  the 
latter.  Similarly,  a  fontanelle  presentation  is  produced  by  a  very 
slight  displacement  of  the  head,  but  its  occurrence,  as  we  shall 
subsequently  see,  tends  to  show  the  existence  of  a  degree  of  pelvic 
narrowing  which  is  sufficient  to  alter  the  mechanism  of  labour. 
Consequently,  it  cannot  be  regarded  as  of  less  importance  than  a 
face  presentation.  If  a  fontanelle  presentation  is  to  be  considered 
as  a  variety  in  the  mechanism  of  a  vertex  presentation,  a  face  or  a 
brow  presentation  —  i.e.,  any  resultant  presentation — must  be 
similarly  considered,  as  it  is  not  logically  possible  to  differentiate 
between  them.  Consequently,  we  consider  that  it  is  necessary 
to  adopt  the  foregoing  extended  classification  of  presentations. 
It  is  a  common  mistake  to  consider  that  the  presentation  once 

9—2 


132        OBSTETRICAL  ANATOMY— MATERNAL  AND  OVULAR 

fixed  is  unchangeable,  even  though  the  occurrence  of  secondary 
presentations  clearly  proves  the  possibility  of  the  presentation 
altering.  The  error  is  in  large  part  due  to  the  fact  that  works 
on  obstetrics  must,  for  the  sake  of  clearness,  describe  each 
presentation  separately,  and,  consequently,  students  and  others 


Fig.  95. — Diagram  of  Brow  Presentation. 

are  led  into  the  belief  that  a  vertex  presentation  is  through  the 
whole  of  labour  a  presentation  of  the  vertex,  and  a  brow  presenta- 


Fig.  96. — Diagram  of  Anterior 
fontanelle  presentation. 


Fig.  97. — Diagram  of  Posterior 

fontanelle  presentation. 


tion  a  presentation  of  the  brow.  This  is  very  far  from  being  the 
case,  and  especially,  in  view  of  the  extended  classification  of 
presentations  which  we  have  adopted,  this  point  must  be  clearly 


THE  POSITION  OF  THE  FCETUS 


133 


understood.  A  vertex  presentation  changes  in  the  normal 
mechanism  of  labour  as  it  passes  through  the  brim  into  a 
posterior  fontanelle  presentation.  Under  abnormal  circumstances, 
it  may  change  into  a  posterior  fontanelle  presentation  before  it 
can  enter  the  brim,  or  into  an  anterior  fontanelle  presentation , 
or  it  may  change  into  a  brow  or  a  face ;  whilst,  similarly, 
a  brow  or  a  face  presentation  may  change  into  a  vertex.  This 
being  so,  how  is  it  possible  to  classify  presentations  ?  They  are 
classified  according  to  the  presentation  in  which  the  foetus  passes, 
or  attempts  to  pass,  through  the  brim  of  the  pelvis — i.e.,  through 
the  area  of  maximum  resistance,  and  any  previous  or  subsequent 
variations  in  the  presentation  are  neglected.  This  brings  us  to 
a  very  important  practical  point.  We  can  never  be  certain  what 
the  presentation  is  going  to  be  until  the  head  is  fixed  in  the  brim 
of  the  pelvis. 

The    different    lies    and   presentations    may   be    tabulated    as 
follows  : — 


Longitudinal 

lies 

(99-44  per 

cent. ) 


Cephalic 

presentation 

(9633  per 

cent.) 

Pelvic 

presentation 

(3-11  per 

cent. ) 


'  Vertex  (9553  per  cent.) 
Face  (o-6  per  cent.) 
Brow  (o*2  per  cent.) 
Anterior  fontanelle 
Posterior  fontanelle 

Complete  pelvis 

Incomplete  pelvis 


(  Breech 
<   Knee 
Foot 


Transverse 
lies 
(0-56  per 
cent.) 


Shoulder  presentation 


Shoulder 

Elbow 

Hand 


Position. — The  term  '  position  '  is  used  to  express  the  relation 
between  some  fixed  part  of  the  foetus  in  utero  and  the  middle  line 
of  the  mother.  According  to  the  lie  of  the  foetus,  different  parts 
are  chosen  to  indicate  the  position.  In  longitudinal  lies,  the  back 
is  used  as  what  may  be  termed  the  indicator  (the  French  point 
de  repere).  If  the  back  of  the  foetus  is  turned  towards  the  left 
side  of  the  mother,  the  foetus  is  said  to  be  in  the  first  position  ;  if 
the  back  is  turned  towards  the  right  side,  the  foetus  is  said  to  be 
in  the  second  position.  In  transverse  lies,  the  head  is  used  as 
the  indicator.  If  the  head  of  the  foetus  is  on  the  left  of  the  middle 
line,  the  foetus  is  said  to  be  in  the  first  position  ;  if  on  the  right 
of  the  middle  line,  in  the  second  position.  These  two  positions 
can  be  subdivided,  if  necessary,  into  two  sub-positions,  according 
as  the  back  is  turned  towards  the  front  or  the  back  of  the 
mother.  In  this  manner,  the  four  positions  of  Naegele  are  ob- 
tained in  longitudinal  lies,  or  the  four  positions  of  Winckel  in 
transverse  lies. 


134       OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 

There  does  not,  however,  appear  to  be  any  real  reason  for 
recognising  four  positions.  In  the  first  place,  the  mechanism 
of  labour  is  very  little  affected  by  the  fact  that  the  back  is 
directed  anteriorly  or  posteriorly.  In  the  second  place,  even  if 
four  positions  are  recognised,  still  the  foetus  may  lie  in  a  posi- 


A  B 

Fig  98. — Diagram  of  '  Position  '  in  Longitudinal  Lie  of  Fcetds. 
A,  First  position,  back  to  left ;  B,  second  position,  back  to  right. 

tion  which  does  not  correspond  with  any  of  them — i.e.,  with 
back  directed  neither  forwards  nor  backwards,  but  midway 
between  these  two  positions.  In  the  third  place,  any  necessity 
for  defining  the  position  of  the  foetus  exactly  can  be  met  by 
qualifying  the  term  first  and  second  position  by  adding  the  words 


A  B 

Fig.  99. — Diagram  of  '  Position  '  in  Transverse  Lie. 

A,  First  position,  head  to  left ;  B,  second  position,  head  to  right. 

<  with  the  back  in  front '  or  '  with  the  back  behind,'  as  the  case 
may  be.  Accordingly,  we  shall  describe  only  two  positions,  but 
in  each  case  we  shall  also  add  the  positions  of  Naegele  or 
Winckel  for  the  benefit  of  those  who  are  accustomed  to  such  a 
classification. 


THE  POSITION  OF  THE  FCETUS 


'35 


In  longitudinal  lies,  the  commonest  position  is  the  first  position 
with  the  back  in  front.  The  proportion  of  cases  in  which  it 
occurs  is  greatest  in  cephalic  presentations,  as  we  shall  presently 
see.  In  pelvic  presentations,  it  is  also  more  frequent,  but  its  pre- 
ponderance is  not  so  marked.  The  preponderance  of  first  positions 
in  cephalic  presentations  is  largely  attributable  to  the  influence  of 
gravity.  As  has  been  already  said,  if  a  foetus  is  immersed  in  a 
fluid  of  the  same  density  as  the  liquor  amnii,  it  floats  on  its  back, 
its  head  lower  than  its  breech,  and  its  right  shoulder  lower  than 
its  left.  When  the  mother  stands  upright,  the  uterus  falls  forwards 
and  slightly  to  the  right,  so  that  its  most  dependent  part  is  found 
in  the  right  iliac  fossa.  Consequently,  the  foetus,  under  the 
influence  of  gravity,  tends  to  lie  with  its  head  presenting,  its  back 
anterior,  and  its  right  shoulder  in  the  right  iliac  fossa.  That  is 
to  say,  it  lies  in  the  first  position  with  the  back  in  front.  Another 
cause  of  the  frequency  of  this  position  is  to  be  found  in  the  rela- 
tion between  the   horizontal  diameters  of   the   uterus    and    the 


Fig.  100. — The  Fcetus  as  seen  from  Above,  showing  the  Correspondence 
between  the  antero-posterior  diameters  of  the  fcetal  ovoid, 
the  Transverse  Diameter  of  the  Uterus,  and  the  Right  Oblique 
Diameter  of  the  Pelvis. 


horizontal  diameters  of  the  foetus.  The  greatest  horizontal 
diameter  of  the  uterus  is  the  transverse  diameter,  and  the  greatest 
horizontal  diameter  of  the  foetal  ovoid  is  the  antero-posterior 
diameter.  Accordingly,  the  foetus  accommodates  itself  best  to 
the  shape  of  the  uterus  when  it  lies  with  its  antero-posterior 
diameter  in  the  transverse  diameter  of  the  uterus.  Now,  in  con- 
sequence of  the  usual  dextro-torsion  of  the  uterus,  its  transverse 
diameter  corresponds  with  the  right  oblique  diameter  of  the 
pelvis,  and  consequently  the  antero-posterior  diameter  of  the 
foetal  ovoid  is  found  in  the  same  position.  A  third  reason  for 
the  preponderance  of  the  first  position  with  the  back  in  front 
may  perhaps  be  found  in  the  fact  that,  owing  to  the  presence 
of  the  rectum,  the  left  oblique  diameter  of  the  pelvis  is  slightly 
shorter  than  the  right,  and  that,  consequently,  there  is  more 
space  for  the  long  diameters  of  the  head  in  the  larger  right 
oblique  diameter. 


136       OBSTETRICAL  AN  ATOMY— MATERNAL  AND  OVULAR 


Longitudinal 
lies 


The  various  positions  may  be  tabulated  as  follows  : — ■ 

{  In   front,  first  position 
'!  of  Naesrele 

First  position,  back  to  the  left    I    BehinAi  fourfh  position 

1^  of  Naegele 

In  front,  second   posi- 
tion of  Naegele 
Behind,  third  position 
of  Naegele 

Back  in  front,  first 
position  of  Winckel 

Back  behind,  fourth 
position  of  Winckel 

Back  in  front,  second 
position  of  Winckel 

Back  behind,  third 
position  of  Winckel 


Transverse  lies 


Second   position,   back    to  the 
right 


First  position,  head  to  the  left 


Second  position,  head   to   the 
I  right 


PART   II 

OBSTETRICAL  ASEPSIS  AND  ANTISEPSIS 

THE  OBSTETRICAL  ARMAMENTARIUM 

OBSTETRICAL  DIAGNOSIS 


CHAPTER  I 
OBSTETRICAL  ASEPSIS  AND  ANTISEPSIS 

History — Definitions — The  Causes  of  Septic  Infection — The  Bacteriology  of 
the  Genital  Tract :  the  Vulva,  the  Vagina,  the  Uterine  and  Cervical 
Cavities — The  Prevention  of  Sepsis  :  the  Disinfection  of  the  Hands, 
Sterilisation  of  Instruments,  the  Disinfection  of  the  Genital  Passages,  the 
Administration  of  Douches. 

In  1847,  Semmelweis  of  Vienna  drew  the  attention  of  his  colleagues 
to  the  enormous  death-rate  from  puerperal  fever  in  the  lying-in 
wards  of  the  General  Infirmary  of  Vienna — a  mortality  which 
exceeded  12  per  cent.  He  was  led  by  various  incidents  to  ascribe 
this  mortality  to  the  infection  of  the  patients  by  students,  who 
came  straight  from  the  dissecting-rooms  to  the  lying-in  wards, 
and  there  made  vaginal  examinations  with  insufficiently  washed 
hands.  With  the  view  of  diminishing  this  terrible  mortality,  he 
enforced  certain  regulations,  particularly  the  thorough  washing 
of  the  hands  in  a  solution  of  chlorine  before  making  vaginal 
examinations,  with  the  result  that  the  death-rate  was,  within  a 
comparatively  short  period,  reduced  from  12-24  per  cent,  to 
1-27  per  cent.  In  spite  of  this  clear  demonstration  of  the  cause 
of  the  death-rate,  the  general  adoption  of  cleanliness  and  dis- 
infectants was  very  slow.  For  many  years,  puerperal  fever  was 
still  considered  to  be  due  to  ill-defined  causes,  such  as  the  weather, 
the  temperament  of  the  patient,  and  the  workings  of  Providence  ; 
and,  what  was,  perhaps,  a  still  greater_  cause  of  confusion, 
puerperal  fever  was  considered  to  be  a  disease  peculiar  to  par- 
turient women,  and  its  connection  with  the  '  surgical '  infection 
of  wounds  and  with  pyaemia  remained  unrecognised. 

The  statistics  of  the  great  Rotunda  Hospital  show  that  the 
results  of  the  introduction  of  asepsis  into  the  practice  of  that 
Institution  were  very  marked,  although  at  no  time  was  the  death- 
rate  at  all  comparable  with  that  of  the  Viennese  Hospital  at  the 
time  of  Semmelweis,  owing  doubtless  to  the  fact  that  there  was 
no  medical  school  or  dissection-rooms  in  association  with  the 
maternity  department.  During  the  years  1846  to  1853 — that  is, 
during  the  time  at  which  Semmelweis  was  teaching  at  Vienna, 
13,501  women  were  confined  in  the  Rotunda  Hospital. :;:     Of  this 

*   '  Lectures  on  Midwifery,'  by  E.  W.  Murphy,  M.D.     London,  1862,  p.  705. 

139 


i4o  OBSTETRICAL  ASEPSIS  AND  ANTISEPSIS 

number  177  died,  being  a  percentage  mortality  of  1*31,  a  wide 
difference  indeed  from  Semmelweis's  figures.  During  the  years 
1868  to  1875,  9,760  women  were  confined  in  the  hospital.*  Of 
this  number  179  died,  being  a  percentage  mortality  of  2-21.  More 
than  twenty  years  had  elapsed,  but  instead  of  a  diminution  in 
the  mortality,  an  actual  increase  of  almost  one  per  cent,  had 
taken  place.  During  the  closing  years  of  the  nineteenth  century, 
from  1893  to  1900,-f-  10,219  women  were  confined  in  the  hospital. 
Of  this  number  38  died,  a  percentage  mortality  of  0-37 — that 
is  to  say,  in  a  further  period  of  twenty-five  years  the  mortality 
was  reduced  to  a  sixth  of  what  it  had  been. 

These  figures  suggest  two  interesting  questions — -How  was  it 
that  at  a  time  when  in  Vienna  the  death-rate  was  12  per  cent., 
the  death-rate  in  Dublin  was  1*31  per  cent.?  And  why  should 
there  have  been,  after  a  lapse  of  twenty  years,  an  increase  in  the 
death-rate  of  nearly  one  per  cent.,  followed  after  a  similar  period 
by  so  marked  a  decrease  ?  The  answer  to  the  first  question  has 
been  in  part  given,  but  it  is  probable  that  another  reason  was 
also  to  be  found  in  the  fact  that  in  Dublin  the  use  of  chlorine 
as  a  disinfectant  had  been  practically  applied  some  thirty  years 
before  Semmelweis  proved  its  value  in  Vienna.  Collins,  Master 
of  the  Rotunda  Hospital  from  1826  to  1833,  was  obliged  to  tem- 
porarily close  the  hospital  on  account  of  a  severe  epidemic  of 
puerperal  fever.  While  it  was  closed,  he  had  all  the  wards  in 
rotation  '  filled  with  chlorine  gas  in  a  very  condensed  form  for 
the  space  of  forty-eight  hours  ';}  the  floors  and  woodwork  were 
also  painted  over  with  chloride  of  lime,  which  was  left  on  for 
forty-eight  hours  more.  This  was  done  in  the  year  1829,  and 
from  that  time  to  the  end  of  his  mastership  in  1833,  he  '  did  not 
lose  one  patient  from  this  disease.'  The  number  of  deaths  which 
had  occurred  in  the  hospital  in  the  four  years  preceding  this  dis- 
infection were  81,  33,  43,  34,  and  in  the  four  years  following  it 
12,  12,  12,  12. 

The  second  question  also  admits  of  a  very  probable  answer. 
During  the  period  1853  f°  J  868,  there  was  no  real  advance  in  the 
knowledge  of  the  prevention  of  puerperal  fever.  Hygienic 
advances  were  doubtless  made,  but  these,  though  important  in 
themselves,  are  not  sufficient  to  cope  with  the  factors  of  septic 
infection.  On  the  other  hand,  there  was  a  distinct  advance  in 
what,  for  want  of  a  better  term,  we  may  call  the  science  of  mid- 
wifery as  opposed  to  the  practice  of  this  subject.  The  use  of 
the  forceps  became  more  general,  and  various  other  operations 
were  more  commonly  practised,  with  the  results  that  the  oppor- 
tunities for  infecting  a  patient  were  indefinitely  increased. 

*   '  Clinical  Reports  of  the  Rotunda  Hospital,'  by  George  Johnston.     1868- 

1875- 
t  '  A  Short  Practice  of  Midwifery,'  by  Henry  Jellett.     Fourth  edition,  1903, 

PP-  534.  535- 

J  '  A  Practical  Treatise  on  Midwifery,'  by  Robert  Collins.     London,  1835, 
p.  388. 


THE  INTRODUCTION  OF  ANTISEPSIS  141 

The  enormous  improvement  in  the  death-rate  from  this  time 
on  is  readily  accounted  for.  The  discoveries  of  Lister  and  Pasteur 
lead  to  the  identification  of  puerperal  fever  and  septic  infection, 
or  perhaps  it  is  more  correct  to  say  they  lead  to  the  discovery 
that  there  was  no  such  thing  as  puerperal  fever,  and  that  the 
conditions  which  had  been  grouped  under  this  term  were  identical 
with  the  results  of  the  septic  infection  of  wounds.  Once  this 
point  was  clearly  grasped  by  medical  men,  the  improvement  in 
the  mortality  from  septic  infection  became  greater  each  year, 
until  at  the  present  time  lying-in  hospitals,  which  in  former  days 
were  the  most  dangerous,  are  now  the  safest  places  in  which  a 
woman  can  be  confined. 

With  the  foregoing  statistics  before  us,  we  need  not  dwell 
upon  the  necessity  for  the  rigid  practice  of  asepsis  and  anti- 
sepsis in  obstetrical  practice.  It  is  essential  in  an  obstetrician 
that  he  should  recognise  this  necessity  and  act  accordingly.  An 
obstetrician  who  does  not  recognise  this,  no  matter  how  skilled 
he  may  be,  will  be  a  source  of  danger  rather  than  of  safety  to  his 
patient.  We  shall  therefore  first  describe  the  sources  of  septic 
infection,  as  when  they  are  known  the  methods  of  avoiding  them 
will  be  more  readily  understood.  Before  doing  so,  however,  it 
will  be  well  to  define  certain  terms  of  which  we  shall  make  use. 

By  the  term  '  sterile  '  is  meant  the  entire  absence  of  living 
micro-organisms.  By  the  term  '  aseptic '  is  meant  the  entire 
absence  of  septic  organisms.  By  the  term  '  antiseptic  '  is  meant 
any  substance  which  is  capable  of  inhibiting  the  growth  of,  or  of 
destroying,  septic  organisms.  These  are  all  definite  terms,  but 
the  next  term  is  by  no  means  so  definite — i.e.,  '  surgical  cleanli- 
ness.' The  meaning  which  we  should  like  this  term  to  convey 
and  the  meaning  which  we  are  compelled  by  circumstances  to 
attach  to  it  are  widely  different.  The  object  of  all  research  into 
the  different  modes  of  sterilisation  is  to  make  surgical  cleanli- 
ness correspond  as  closely  as  possible  with  sterility.  This,  un- 
fortunately, it  is  as  yet  impossible  to  do  in  the  majority  of 
cases  Sterility  is  almost  impossible  on  account  of  the  number 
of  saprophytic  organisms  which  are  in  the  air.  The  highest  form 
of  surgical  cleanliness  to  which  we  can  attain  is  in  the  case  of 
those  substances  which  can  be  exposed  to  the  prolonged  action  of 
heat—  e.g.,  dressings  and  instruments,  and  even  here  the  term  is 
at  best  usually  synonymous  with  asepsis,  while  in  the  case  of  our 
hands,  or  of  the  skin  of  the  patient,  we  can  rarely,  if  ever,  attain 
to  such  a  height.  In  their  case,  the  most  that  can  be  hoped  for  is 
that  the  external  layers  of  the  skin  are  rendered  aseptic  while  the 
deeper  layers  are  still  swarming  with  micro-organisms.  For- 
tunately, as  practice  proves,  this  is  sufficient.  The  term  '  surgical 
cleanliness '  must,  then,  be  taken  to  mean  the  nearest  approach  to 
sterility  which  can  be  obtained  by  the  careful  carrying  out  of 
those  methods  which  experience  has  proved  to  be  most  reliable. 
The  last  term,  '  sterilisation,' is  that  usually  applied  to  the  process 


1 42  OBSTETRICAL  ASEPSIS  AND  ANTISEPSIS 

by  which  hands,  instruments,  etc.,  are  rendered  surgically  clean. 
It  is  obviously  not  a  perfectly  correct  term,  but  inasmuch  as  it 
conveys  the  end  at  which  we  are  aiming,  and  so  always  keeps  it 
before  us,  it  is  an  extremely  suitable  one. 

Lastly,  there  are  two  terms  which  have  been,  and  are  still,  used 
to  denote  two  supposed  sources  of  septic  infection  : — '  Autogenetic 
infection,'  or,  more  shortly,  '  auto-infection,'  is  the  term  applied 
to  the  inoculation  of  the  patient  by  bacteria  which  are  present 
under  normal  circumstances  in  the  body.  '  Heterogenetic 
infection,'  or  '  hetero-infection,'  is  the  term  applied  to  the  inocula- 
tion of  the  patient  by  bacteria  which  have  been  directly  or 
indirectly  introduced  from  without,  and  which  are  not  present 
in  the  body  under  normal  circumstances.  A  clear  distinction 
must  be  made  between  these  terms,  inasmuch  as  it  is  doubtful 
whether  auto-infection  ever  occurs. 

The  cause  of  septic  infection  is  the  invasion  of  the  tissues  of 
the  body  by  septic  organisms  ;  and  in  this  term  we  include  the 
streptococcus  and  the  staphylococcus,  the  gonococcus  and  the 
diphtheria  bacillus.  It  is  obvious  that  any  of  these  bacteria  may 
be  introduced  into  the  genital  tract  from  without,  and  so  give  rise 
to  hetero-infection.  If,  however,  they  are  also  present  in  the 
genital  tract  under  normal  circumstances,  awaiting,  as  it  were,  a 
favourable  opportunity  for  gaining  access  to  the  tissues  of  the 
body,  then  auto-infection  is  also  possible.  Whether  auto-infection 
is  or  is  not  possible  is  a  most  important  question  to  decide,  as  on 
the  answer  to  it  are  necessarily  based  the  various  methods  of 
preventing  the  occurrence  of  septic  infection.  To  answer  it,  we 
must  study  the  bacteriology  of  the  genital  tract. 


THE  BACTERIOLOGY  OF  THE  GENITAL  TRACT 

The  genital  tract  may  for  bacteriological  purposes  be  divided 
into  three  zones,   each  of  which  will  be  found  to  have  its  own 
bacterial  peculiarities.     These  zones  are  as  follows: — - 
(i)  Outside  the  hymen — i.e.,  the  vulva. 

(2)  From  the  hymen  to  the  external  os — i.e.,  the  vagina. 

(3)  Above  the  external  os  —  i.e.,  the  cervical  and  uterine 

cavities. 
The  Vulva. — The  vulva  and  all  the  parts  surrounding  it  may 
be  termed  the  septic  area  of  the  genital  passages.  Their 
bacteriology  is  more  or  less  identical  with  that  of  the  skin  of  the 
rest  of  the  body,  save  that  owing  to  the  juxtaposition  of  the  anus 
the  bacterial  flora  is  perhaps  more  abundant.  The  bacteria  most 
commonly  met  with  are  the  Streptococcus  and  Staphylococcus  aureus, 
the  Staphylococcus  albus  and  the  Staphylococcus  epidermidis  alius,  the 
vaginal  bacillus,  Bacillus  coli  communis,  numerous  forms  of  sapro- 
phytic bacteria,  and  yeast  cells.  It  must  be  remembered  that 
infection  by  these  bacteria  cannot  be  termed  auto-infection,  any 


THE  BACTERIOLOGY  OF  THE  GENITAL   TRACT  143 

more  than  the  infection  carried  on  the  patient's  fingers  to  the 
genital  tract  could  be  so  termed.  The  presence  of  bacteria  on  the 
vulvar  skin  is  accidental,  as  in  the  case  of  the  skin  of  other  parts 
of  the  body,  and,  consequently,  infection  by  these  bacteria  is 
distinctly  heterogenetic. 

The  Vagina. — The  bacteriology  of  the  vulva  has  been  dismissed 
in  a  few  words,  but  that  of  the  vagina  is  more  complicated  and 
uncertain.  The  difficulty  of  determining  exactly  the  bacterial  con- 
ditions of  the  vagina  in  health  is  great,  a  fact  which  is  well  shown 
by  the  contradictory  results  obtained  by  competent  authorities. 

In  1892,  Doederlein  published  a  monograph*  on  vaginal 
secretion,  in  which  he  incorporated  the  results  of  his  examination 
of  the  vaginal  secretion  of  195  pregnant  women.  He  believed 
that  he  could  distinguish  two  varieties  of  secretion — normal  and 
abnormal.  The  normal  secretion  was  a  thick,  dryish,  crumbly, 
white  material,  with  a  very  markedly  acid  reaction.  On  micro- 
scopical examination,  it  was  found  to  be  composed  of  epithelial 
cells,  of  large  numbers  of  long,  tolerably  thick  bacilli,  and  occa- 
sionally of  a  few  yeast  cells.  The  abnormal  secretion,  on  the 
other  hand,  was  more  fluid  in  character  and  purulent  in  appear- 
ance, and  less  acid  or  occasionally  alkaline  or  neutral  in  reaction. 
Upon  microscopical  examination,  it  was  found  to  contain  leuco- 
cytes and  epithelial  cells,  and  many  varieties  of  bacteria,  especially 
cocci  and  short  bacilli.  Cultures  made  from  the  normal  secretion 
were,  as  a  rule,  sterile,  but  from  the  abnormal  secretion  various 
pyogenic  organisms  could  be  isolated.  Classifying  the  cases  he 
examined  on  this  basis,  Doederlein  considered  that  in  53-3  per 
cent,  the  secretion  was  normal,  in  44-6  per  cent,  abnormal. 
Whitridge  Williams,!  in  1893,  published  the  results  of  an  ex- 
amination of  fifteen  cases,  results  which  in  the  main  agreed 
with  Doederlein.  The  practical  outcome  of  Doederlein's  work 
was  to  point  to  the  possibility  of  auto-infection,  and  hence  to 
the  necessity  for  prophylactic  vaginal  douches. 

In  1894,  Kroenig,  who  had  succeeded  Doederlein  at  Leipzig, 
published  the  result  of  his  examination  of  100  cases,  J  results 
which  were  directly  opposed  to  those  of  Doederlein.  Kroenig 
stated  that  '  the  vaginal  secretion  of  pregnant  women  who  had 
not  been  examined,  no  matter  whether  normal,  pathological,  or 
highly  pathological,  never  contained  organisms  which  grow 
aerobically  upon  the  ordinary  media  at  the  body  temperature, 
except  yeast  and  gonococci,  and  therefore  never  contained  septic 
bacteria.  The  vagina  of  every  pregnant  woman  who  has  not 
been  examined  is  therefore  aseptic'  Later  in  the  same  year, 
Kroenig  published  another  article  on  the  effect  of  the   vaginal 

*  '  Das  Scheidensekret,'  Leipzig,  1892. 

f  '  Puerperal  Infection  considered  from  a  Bacteriological  Point  of  View,' 
American  Journal  of  Medical  Sciences,  July,  1893. 

%  '  Scheidensekretuntersuchungen  bei  100  Schwangeren.  Aseptik  in  der 
Geburtshulfe,'  Centralb.  f.  Gyn.,  1894,  3-10. 


i44  OBSTETRICAL  ASEPSIS  AND  ANTISEPSIS 

secretion  on  bacteria.*  In  this,  he  stated  that  the  secretion,  no 
matter  what  its  character,  possessed  a  markedly  bactericidal 
action  upon  pathological  organisms  ;  and  '  that  we  may  consider 
the  vagina  of  a  pregnant  woman  as  aseptic  if  we  are  sure  that  two 
or  three  days  have  elapsed  since  she  was  examined.'  This 
bactericidal  action  was  found  to  be  more  marked  the  nearer  to 
the  cervix  the  test-growth  was  placed,  and  to  be  weakened 
or  destroyed  by  antiseptic  douches.  It  had  been  already  described 
by  Doederlein,f  who  attributed  it  to  the  acidity  of  the  vaginal 
discharge,  caused  by  the  presence  of  the  vaginal,  or  lactic  acid, 
bacillus.  Kroenig  further  attributed  this  effect  to  phagocytic 
action  and  lack  of  oxygen. 

Kroenig  did  not  stand  alone  in  his  opinions.  The  same  year 
that  he  published  the  article  which  has  been  referred  to,  Menge 
also  published  the  results  of  the  examination  of  fifty  non-pregnant 
women,  J  in  whom  he  had  found  the  same  bactericidal  powers  of 
the  vaginal  secretion,  though  they  were  not  so  marked  as  in 
pregnant  women.  In  other  ways  he  also  confirmed  Kroenig's 
work. 

In  1897,  Menge  and  Kroenig  published  jointly  a  work  in  which 
the  results  of  the  examination  of  sixty-seven  additional  cases  was 
recorded.  §  From  the  united  results  of  these  and  of  the  former 
cases,  they  confirmed  their  previous  statement  as  to  the  absence 
of  pyogenic  organisms  from  the  vaginal  secretion. 

The  differences  between  the  results  obtained  by  Menge  and 
Kroenig,  and  by  Doederlein,  Whitridge  Williams,  and  others, 
were  stated  by  Kroenig  to  be  due  to  faulty  technique,  whereby 
the  septic  organisms  on  the  vulva  were  carried  up  into  the 
vagina  in  the  course  of  the  removal  of  a  specimen  of  the  secretion 
for  examination.  With  a  view  to  either  proving  or  disproving 
this,  Williams  undertook  a  fresh  series  of  examinations  on  ninety- 
two  women,  with  a  technique  which  rendered  the  possibility  of 
contamination  of  the  vaginal  secretion  very  small.  The  results 
of  this  examination  are  embodied  in  a  most  interesting  article,  || 
which  was  read  before  the  American  Gynaecological  Society,  and 
to  which  we  are  indebted  for  much  information  relating  to  the 
work  of  previous  investigators.  Williams'  work  gives  almost 
unqualified  support  to  Kroenig's  statements  in  the  matter  of 
septic  organisms.  In  only  two  cases  could  he  find  cocci  in  the 
secretion,  and  these  cocci  were  not  such  as  are  found  in  puerperal 
infection.  On  the  other  hand,  he  found  several  forms  of  aerobic 
bacilli  as  follows  : — 

*  '  Ueber  das  bakterienfeindliche  Verhalten  des  Scheidensekretes  Schwan- 
geren,'  Deutsche  Med.  W  ochenschrift,  1894,  No.  43. 

t  Op.  cit. 

X  '  Ueber  ein  bakterienfeindliches  Verhalten  der  Scheidensekrete  Nicht- 
schwangerer,'  Deutsche  Med.  W 'ochenschrift.  1894,  Nos.  46-48. 

§  '  Baktei*iologie  des  Weiblichen  Genitalkanales. '     Leipzig,  1897. 

IJ  '  The  Bacteria  of  the  Vagina,'  Transactions  of  the  American  Gynecological 
Society,  1898,  p.  141. 


THE  BACTERIOLOGY  OF  THE  GENITAL  TRACT  145 

(1)  The  vaginal  bacillus  in  30-4  per  cent,  of  the  cases. 

(2)  Long,  thick  bacilli,  resembling  the  vaginal  bacillus,  in 
i7'4  per  cent,  of  the  cases. 

(3)  Short,  thick  bacilli  in  about  12  per  cent,  of  the  cases. 

(4)  Gas-producing  bacilli  in  3-2  per  cent,  of  the  cases. 

Also  various  forms  of  anaerobic  bacilli  were  found  in  about 
16  to  17  per  cent,  of  the  cases,  and  included  one  form  of  gas- 
producing  bacillus.  None  of  these  bacilli — aerobic  or  anaerobic — 
appeared  to  possess  any  pathogenicity. 

Williams  further  endeavoured  to  divide  his  cases  into  those 
with  normal  and  those  with  abnormal  secretion,  according  to  the 
criteria  of  Doederlein,  but  apparently  without  any  practical 
result.  He  did  not  find  that  the  characteristics  which  Doederlein 
described  were  in  all  cases  a  correct  index  of  the  bacterial  contents 
of  the  secretion.  Moreover,  his  tables  showing  the  relative  course 
of  the  puerperium  in  the  cases  of  so-called  normal  and  abnormal 
secretion  do  not  definitely  show  that  there  was  any  causal 
relationship  between  '  abnormal  secretion '  and  subsequent  eleva- 
tion of  temperature. 

The  conclusions  which  are  drawn  by  Williams  from  his  own 
examinations  are  as  follows  : — 

(1)  The  vaginal  secretion  of  pregnant  women  does  not  contain 
the  usual  pyogenic  cocci. 

(2)  The  discrepancy  in  the  results  of  previous  investigators  was 
due  to  the  manner  in  which  the  secretion  was  obtained. 

(3)  As  the  vagina  does  not  contain  pyogenic  cocci,  auto- 
infection  is  impossible.  Consequently,  when  such  cocci  are  found 
in  the  uterus,  they  have  been  introduced  from  without. 

(4)  The  gonococcus  is  occasionally  found  in  the  vaginal 
secretion,  and  during  the  puerperium  may  extend  from  the  cervix 
into  the  uterus  and  tubes. 

(5)  It  is  possible  that,  in  rare  instances,  the  vagina  may  contain 
bacteria  which  give  rise  to  sapraemia  and  putrefactive  endometritis 
by  auto-infection.  If  such  cases  occur,  they  are  usually  not 
severe,  and  do  not  cause  death. 

(6)  Death  from  puerperal  infection  is  always  due  to  infection 
from  without,  and  is  usually  due  to  the  neglect  of  aseptic  pre- 
cautions on  the  part  of  the  physician  or  nurse. 

(7)  Puerperal  infection  is  to  be  avoided  by  limiting  vaginal 
examinations  as  much  as  possible  and  by  cultivating  abdominal 
palpation.  When  vaginal  examinations  are  to  be  made,  the 
external  genitals  should  be  carefully  cleansed  and  the  hands 
rendered  as  aseptic  as  for  a  surgical  operation.  Vaginal  douches 
are  not  necessary,  and  are  probably  harmful. 

These  conclusions  represent  very  fairly  the  extent  of  our  know- 
ledge of  the  bacteriology  of  the  vagina.  They  may  be  summed  up 
in  a  few  words : — The  healthy  vagina  is  an  aseptic  canal,  and 
prophylactic  vaginal  douches  are  consequently  not  necessary. 

We  have  quoted  Kroenig  as  stating  that  even  the  pathological 

10 


146  OBSTETRICAL  ASEPSIS  AND  ANTISEPSIS 

or  highly  pathological  secretion  of  pregnant  women  never  con- 
tained septic  bacteria.  This  statement  must,  however,  surely  be 
qualified.  Doubtless  his  experiments  tend  to  show  that,  so  long 
as  the  influence  of  the  vaginal  bacillus  and  the  other  causes  of 
vaginal  asepsis  were  paramount,  septic  organisms  rapidly  dis- 
appeared, but,  on  the  other  hand,  he  advances  no  proof  that 
the  action  of  the  vaginal  bacillus  cannot  be  overcome  by  excessive 
numbers  of  pyogenic  cocci,  a  result  which  is  bound  to  occur  in 
certain  cases.  Where  septic  abscesses  drain  into  the  vagina,  or 
where  septic  vaginitis  or  other  septic  conditions  of  the  vaginal 
walls  is  present,  the  vagina  must  contain  septic  organisms  so  soon 
as  the  strength  of  the  invading  bacteria  overcomes  the  resistance 
of  the  vaginal  bacillus. 

The  Uterine  and  Cervical  Cavities. — The  bacteriology  of  the 
uterine  and  cervical  cavities  is  perhaps  more  settled  than  is  that 
of  the  vagina.  Winter  examined  a  number  of  healthy  uteri,  and 
came  to  the  following  conclusions  : — * 

(1)  The  healthy  uterine  cavity  contains  no  bacteria. 

(2)  The  vicinity  of  the  os  internum  contains  no  bacteria  in 
50  per  cent,  of  cases. 

(3)  The  cervical  secretion  of  every  healthy  woman  contains 
numerous  bacteria. 

This  view  has  been  adopted  for  some  time,  and  has  led  to  the 
division  of  the  plug  of  mucus — the  operculum,  which  fills  the 
cervical  cavity — into  three  zones  :  an  upper  sterile  zone ;  a 
middle  bactericidal  zone ;  and  a  lower  germ-containing  zone. 
We  shall  see  presently  to  what  the  bactericidal  action  of  the 
middle  zone  is  due.  Menge  and  Stroganoff,t  on  the  other  hand, 
considered  that  the  dividing  line  between  germ-containing  and 
germ-free  territories  lay  at  the  os  externum.  They  agreed  as  to 
the  bactericidal  action  of  the  cervical  mucus.  Between  these  two 
views  there  is  no  very  essential  difference,  as  they  both  recognise 
that  the  uterine  cavity  is  germ  free,  and  only  differ  in  the  exact 
situation  of  the  dividing  line  between  the  germ-free  and  the 
germ-containing  territories. 

The  cause  of  the  sterile  condition  of  the  uterine  cavity  is,  as  we 
have  mentioned,  in  the  main  the  bactericidal  action  of  the  oper- 
culum, or  plug  of  mucus  which  fills  the  cervical  canal.  Japp 
Sinclair  |  particularises  the  various  causes  of  this  action  as 
follows: — 

(1)  The  difference  in  the  reaction  of  the  cervical  and  the 
vaginal  secretions — a  difference  which  keeps  away  from  the  cervix 
the  facultative  aerobes  and  pathological  organisms  which  some- 
times gain  a  footing  in  the  vagina. 

*  '  Ueber  der  Bakteriengehalt  der  Cervix,'  Centralb.  f.  Gyn.,  1895,  508. 

f  '  Bakteriologische  Untersuchungen  des  Genitalkanales  beim  Weibe  in 
Verschieden  Perioden  ihres  Lebens,'  Monatss.  f.  Gcb.  u.  Gyn.,  1895,  u-  3°5- 
394  and  494-504- 

X  '  A  Text-book  of  Gynaecology,'  edited  by  C.  A.  L.  Reed,  p.  355. 


THE  BACTERIOLOGY  OF  THE  GENITAL  TRACT  147 

(2)  The  muscular  power  of  the  walls  of  the  cervical  canal. 

(3)  The  downward  stream  of  the  cervical  secretion. 

(4)  Some  germicidal  quality  in  the  cervical  secretion — that  is, 
in  the  leucocytes  and  in  the  fluid  which  constitute  the  operculum. 

(5)  The  presence  of  the  gonococcus  when  it  has  gained  access 
to  the  cervix.  It  is  thought  that  the  presence  of  the  gonococcus 
has  a  deterrent  effect  on  the  development  of  other  bacteria.  This 
factor  is,  however,  obviously  of  no  account  in  healthy  uteri. 

The  foregoing  brief  account  of  the  bacteriology  of  the  genital 
passages  can  be  summarised  as  follows  : — The  genital  passages 
may  be  divided  into  three  tracts  or  zones — (a)  a  septic  tract, 
comprising  all  outside  the  hymen ;  (b)  an  aseptic  tract,  comprising 
the  vagina ;  (c)  a  sterile  tract,  comprising  the  uterine  and  cervical 
cavities. 

The  cause  of  the  condition  of  (a)  requires  no  explanation.  The 
aseptic  condition  of  (b)  is  due  to  the  deterrent  action  of  the  vaginal 
or  lactic  acid  bacillus  on  pyogenic  organisms.  The  sterile 
condition  of  (c)  is  due  to  the  bactericidal  action  of  the  constituents 
of  the  operculum. 

After  labour,  the  bacterial  conditions  of  the  genital  passages 
have  markedly  changed.  Instead  of  there  being  three  tracts  or 
zones,  as  have  been  described,  there  are  but  two — a  septic  tract, 
comprising,  as  before,  the  vulva,  and  adjacent  parts  ;  and  a  sterile 
tract,  comprising  the  vaginal  and  uterine  cavities.  In  other 
words,  the  vagina  has  been  changed  from  a  tract  which,  though 
aseptic,  contained  numerous  non-pathogenetic  bacteria,  and 
possibly  some  facultative  saprophytes  to  a  sterile  tract.  This 
change  is  in  all  probability  brought  about  mechanically.  When 
the  membranes  rupture,  the  downward  flow  of  liquor  amnii  sweeps 
away  much  of  the  vaginal  mucus  and  of  its  bacterial  inhabitants. 
As  the  head  descends,  it  dilates  the  vaginal  walls  to  their  utmost 
extent,  and  consequently  enables  the  second  flow  of  liquor  amnii 
to  more  thoroughly  sweep  out  the  vaginal  contents.  Lastly,  the 
birth  of  the  placenta  completes  the  cleansing  of  the  vagina. 

If  any  further  argument  is  necessar)  to  destroy  that  bugbear  of 
obstetrics,  the  possibility  of  true  auto-infection — i.e.,  infection  from 
bacteria  which  are  present  in  the  genital  passages  under  normal 
conditions,  such  proof  is  to  be  found  in  the  statistics  of  the  large 
maternity  hospitals,  which  have  abolished  the  use  of  the  prophy- 
lactic douche  in  normal  cases.  We  cannot  here  enter  into  these 
statistics.  It  is  sufficient  to  say  they  furnish  a  striking  clinical 
proof  of  the  truth  of  Kroenig's  and  Williams'  statements  regarding 
the  asepsis  of  the  normal  vagina. 

We  may,  then,  safely  assume  that  neither  before  nor  after 
labour  is  auto  infection  possible.  If  the  patient  is  infected,  the 
cause  of  the  infection  has  come  from  without,  either  directly  or 
indirectly  from  some  already  infected  area.  Already  existing 
septic  infection  may  be  present  in  the  form  of  septic  or  gonorrhceal 
vulvitis,  urethritis,  vaginitis  or  cervicitis,  as  peri-vaginal  or  peri- 

10 — 2* 


148  OBSTETRICAL  ASEPSIS  AND  ANTISEPSIS 

uterine  abscesses,  as  septically  infected  chancres  or  condylomata, 
or,  in  short,  as  any  form  of  septic  lesion  which  communicates 
directly  or  indirectly  with  the  genital  passages.  Septic  infection 
from  without  can  be  introduced  in  three  ways — by  septic  hands, 
by  septic  instruments,  and  by  carrying  up  septic  matter  from  the 
vagina  and  perinaeum. 

The  prevention  of  the  extension  of  infection  in  already  infected 
cases  will  be  discussed  in  its  proper  place  under  the  treatment  of 
septic  infection.  Here,  we  are  alone  concerned  with  the  pre- 
servation of  asepsis — i.e.,  with  the  prevention  of  the  infection  of 
previously  healthy  patients. 

THE  PREVENTION  OF  SEPSIS 

In  order  to  prevent  the  occurrence  of  septic  infection,  the 
obstetrician  must  determinedly  set  himself  to  ensure  the  surgical 
cleanliness,  or,  if  possible,  the  asepsis,  of  everything  which  comes 
into  contact  with  the  genital  passages  of  the  patient.  x\sepsis 
can  only  be  obtained  in  the  case  of  substances  which  can  be 
submitted  to  the  prolonged  action  of  a  sufficient  degree  of  heat 
or  of  antiseptics  of  sufficient  strength  to  ensure  the  destruction  of 
all  bacteria.  This  can  be  done  in  the  case  of  instruments  and 
dressings,  but  in  the  case  of  the  genital  passages  themselves,  or 
of  the  hands  of  the  operator,  sterility  is  unattainable,  and  the 
obstetrician,  like  the  surgeon,  must  be  content  with  surgical 
cleanliness. 

The  Disinfection  of  the  Hands.- — The  hands  of  the  obstetrician 
furnish  the  most  common  means  by  which  septic  infection  is 
introduced.  Vaginal  examinations  have  to  be  made,  operations 
have  to  be  performed,  and  in  both  these  procedures  the  fingers 
are  in  intimate  relation  with  what  may  be  termed  inocculable 
areas.  Consequently,  the  cleansing  and  disinfection  of  the  hands 
is  of  pre-eminent  importance. 

Many  methods  of  obtaining  surgical  cleanliness  have  from  time 
to  time  been  recommended,  and  as  a  rule  in  surgical  practice 
every  surgeon  has  his  own  favourite  method.  The  range  of 
choice  in  obstetrical  practice  is,  however,  more  limited,  as, 
although  in  hospitals  methods  which  involve  many  details  can  be 
readily  carried  out,  in  general  practice  complicated  processes  are 
impossible.  This,  however,  is  not  altogether  without  its  advan- 
tages. The  adoption  of  complicated  processes  of  disinfecting  the 
hands  sometimes  tend  to  make  an  operator  or  an  obstetrician 
attach  too  much  importance  to  the  use  of  various  kinds  of  chemi- 
cal antiseptics,  to  the  neglect  of  that  most  important  of  anti- 
septics, soap  and  water.  The  use  of  chemical  antiseptics  is 
undoubtedy  a  proper  and  necessary  procedure  when  they  are 
used  in  a  sensible  manner ;  but  this,  unfortunately,  is  not  always 
done.  Medical  men  who  are  not  familiar  with  the  properties  of 
antiseptics  are  sometimes  inclined  to  neglect  them  altogether,  or, 


THE  DISINFECTION  OF  THE  HANDS  149 

on  the  other  hand,  to  attribute  what  is  little  short  of  miraculous 
powers  to  them.  All  antiseptics  require  a  certain  time  in  which 
to  produce  their  effect,  and  few,  if  any,  antiseptics  will  act  on 
bacteria  which  are  protected  by  a  covering  of  grease.  Conse- 
quently, if  we  desire  to  disinfect  our  hands  by  the  use  of  chemical 
antiseptics  solely,  we  must  first  soak  the  hands  in  some  substance 
which  will  dissolve  away  all  fat,  and  then  expose  them  for  the 
necessary  time  to  the  action  of  the  antiseptic  chosen.  Such  a 
process  cannot  always  be  adopted  by  men  in  general  practice, 
and  we  therefore  do  not  recommend  it.  We  have  only  mentioned 
it  to  show  that  splashing  a  finger  or  even  a  whole  hand  through 
an  antiseptic,  and  then  considering  that  the  finger  is  in  a  fit 
condition  to  insert  into  the  vagina,  is  a  practice  akin  to  the 
hereditary  folly  of  the  ostrich. 

The  following  is  a  satisfactory  method  of  disinfecting  the 
hands,  it  possesses  the  advantage  of  not  requiring  the  use  of 
several  different  kinds  of  antiseptics,  and  it  has  stood  the  test  of 
time  at  the  Rotunda  Hospital  and  in  many  other  places.  It  is 
carried  out  as  follows  : — Cut  the  nails  short,  and  remove  gently 
with  a  penknife  any  superfluous  skin  which  may  surround  them. 
Wash  the  hands  with  any  good  soap — carbolic,  if  wished — and  a 
nail-brush  for  from  three  to  five  minutes,  in  plain  water  or  in  a 
one  per  cent,  solution  of  lysol.  Special  attention  must  be  paid  to 
the  nails  and  the  skin  surrounding  them.  Wash  off  all  trace  of 
soap  from  the  hands,  and  then  immerse  them  for  one  minute 
in  a  1  in  500  solution  of  corrosive  sublimate  in  water.  If  the 
obstetrician  does  not  like  corrosive  sublimate,  he  can  substitute 
for  it  mercuric  potassium  iodide,  a  substance  which  has  the 
advantage  over  corrosive  sublimate  that  it  does  not  cause 
blackening  of  the  finger-nails.  It  is  also  said  to  be  more  power- 
ful and  at  the  same  time  to  possess  less  toxic  effects,  and  so  to  be 
less  dangerous.  It  possesses  the  properties  of  the  red  iodide  of 
mercury,  but  is  considerably  more  soluble.  It  is  used  at  a  strength 
of  1  in  1,000. 

In  hospital  practice  or  after  contact  with  pus  or  other  septic 
material  a  more  rigorous  method  of  disinfection  may  be  adopted. 
Reinicke*  states  that  absolute  sterility  is  almost  obtained  by  the 
following  process  : — Scrub  the  hands  for  five  minutes  in  warm 
water  with  soap  and  a  nail-brush.  Then  scrub  them  for  from 
three  to  five  minutes  in  absolute  alcohol,  and  finally  soak  them 
in  an  antiseptic  such  as  corrosive  sublimate.  Kelly,  f  on  the 
other  hand,  recommends  the  use  of  permanganate  of  potash  and 
oxalic  acid.  His  procedure  is  as  follows  : — First,  scrub  the  hands 
and  forearms  for  ten  minutes  with  soap,  warm  water,  and  a  nail- 
brush. The  water  must  be  frequently  changed.  Then,  immerse 
the  hands  in  a  hot,  saturated  solution  of  permanganate  of  potash 
until  they  are  stained  a  deep  mahogany  colour.     Next,  immerse 

*  Centralb.  fur  Gyn.,  November,  1894. 
t  '  Operative  Gynaecology,'  vol.  i. ,  p.  22. 


150  OBSTETRICAL  ASEPSIS  AND  ANTISEPSIS 

them  in  a  saturated  solution  of  oxalic  acid,  which  removes  the 
colour  and  completes  the  sterilisation.  The  oxalic  acid  should  be 
as  warm  as  possible.  Lastly,  remove  the  oxalic  acid  by  rinsing 
the  hands  in  warm  water  or  in  sterilised  lime-water. 

The  introduction  of  rubber  gloves,  which  can  be  boiled,  is  of 
great  advantage  to  the  obstetrician,  as  they  enable  him  to  render 
his  hands  aseptic  at  a  moment's  notice.  If  thin  gloves  are  used 
the  operator's  sense  of  touch  is  little,  if  at  all,  impaired.  The 
gloves  must  be  boiled  before  use,  and  will  be  most  readily  drawn 
on  if  they  are  first  filled  with  a  weak  solution  of  lysol.  Their  use 
by  the  general  practitioner  who  is  obliged  to  attend  all  kinds  of 
cases  is  absolutely  indicated  both  when  making  vaginal  examina- 
tions and  when  performing  obstetrical  operations. 

A  few  words  must  be  said  with  regard  to  the  use  of  lubricants. 
We  hope  that  it  is  unnecessary  at  the  present  day  to  point  out 
the  dangers  of  the  use  of  vaseline  taken  from  a  large  open  oint- 
ment-jar, into  which  clean  and  dirty  fingers  have  been  dipped 
from  time  to  time.  As  a  general  rule,  lubricants  are  unnecessary 
during  labour,  as  the  abundant  mucus  in  the  vagina  acts  as  a  natural 
lubricant.  In  some  cases  it  is,  however,  of  material  service  to 
have  the  fingers  lubricated  with  some  aseptic  substance.  For 
this  purpose,  soap  answers  as  well  as  anything  else.  If  it  has 
been  boiled  in  the  making,  and  if  the  outer  coat  is  first  washed 
off,  we  may  rely  on  its  asepticity.  Antiseptic  lubricants,  which 
can  be  obtained  in  collapsible  tubes,  such  as  corrosive  vaseline, 
may  also  be  used,  if  care  is  taken  to  replace  the  metal  cap  of  the 
tube  after  using.  If  lysol  solution  is  used  with  which  to  wash 
the  hands  a  lubricant  is  not  required,  as  the  soap  which  it  con- 
tains is  sufficient.  It  is  for  this  reason  a  typical  antiseptic  for 
midwifery  practice,  but  it  is  also  well  to  have  a  basin  containing 
corrosive  sublimate  at  hand,  as  the  slipperiness  which  lysol 
imparts  to  the  hands  is  at  times  a  disadvantage. 

Sterilisation  of  Instruments  and  Dressings. — Instruments  which 
can  be  boiled  without  deterioration  admit  of  ready  sterilisation  in 
this  manner.  They  should  first  be  taken  asunder  as  far  as  possible, 
then  scrubbed  with  soap  and  water  and  a  brush,  and  lastly  boiled  for 
at  least  five  minutes  in  a  one  per  cent,  solution  of  common  washing 
soda.  The  latter  is  said  to  prevent  them  from  rusting,  and  is  at 
any  rate  a  good  solvent  of  grease.  To  permit  of  this  method  of 
sterilisation  all  instruments  should  when  possible  be  made  of 
metal,  and  wooden  handles  have  rightly  fallen  into  disuse,  as  it  is 
impossible  to  effectively  sterilise  them.  Dressings,  when  required 
in  operative  cases,  must  be  sterilised  in  the  usual  manner  in  a 
steam  steriliser.  Sanitary  towels  or  diapers  required  after  delivery 
should  be  placed  in  a  i  in  500  solution  of  corrosive  sublimate  at 
the  commencement  of  labour.  They  will  then  be  ready  for  use 
when  required. 

Laminaria  tents  are  occasionally  wanted  in  obstetrical  practice. 
They  must    never   be    used   unless   they  have   been    previously 


THE  DISINFECTION  OF  THE  GENITAL  PASSAGES  151 

thoroughly  sterilised.  This  is  done  by  soaking  them  for  twenty- 
four  hours  in  ether  and  then  storing  them  in  a  one  per  cent,  solution 
of  corrosive  sublimate  in  alcohol,  or  they  may  be  boiled  in  alcohol 
for  twenty  minutes  in  the  author's  catgut  steriliser. 

The  Disinfection  of  the  Genital  Passages. — The  external  genitals 
must  be  disinfected  with  the  greatest  care  at  the  commencement 
of  labour,  as  otherwise,  as  we  have  mentioned,  septic  organisms 
may  be  carried  into  the  vagina,  and  so  the  care  and  trouble  which 
has  been  taken  to  ensure  the  disinfection  of  the  hands  be  rendered 
useless.  Similarly,  during  the  course  of  labour,  the  parts  must  be 
disinfected  afresh  whenever  any  soiling  occurs.  To  disinfect  the 
genitals  at  the  commencement  of  labour,  first  wash  the  parts 
carefully  with  the  hand  and  soap  and  water  or  a  half  per  cent,  lysol 
solution,  taking  care  to  separate  the  labia  and  to  wash  between 
them.  Then,  wash  off  the  soap,  and  bathe  the  parts  well  with  a 
1  in  500  solution  of  corrosive  sublimate.  For  subsequent  disin- 
fection, use  lysol  solution,  as  the  continued  use  of  corrosive 
sublimate  is  prone  to  produce  a  rigid  condition  of  the  peringeum, 


Fig.   ioi. — The  Author's  Catgut  Steriliser. 
A,  Receptacle  for  catgut ;  B,  screw  cover  ;  C,  rubber  washer. 

and  so  to  tend  to  the  occurrence  of  lacerations.  If  it  is  necessary 
to  pass  the  catheter,  care  must  be  taken  to  thoroughly  cleanse  the 
orifice  of  the  urethra. 

We  must  now  discuss  an  important  question  on  which  we  have 
already  touched  when  discussing  the  bacteriology  of  the  genital 
tract.  Is  it  necessary  to  wash  out  the  vagina  during  labour  in 
all  cases  ?  In  other  words,  is  a  prophylactic  douche — i.e.,  a 
douche  given  with  the  object  of  preventing  septic  or  saprophytic 
infection — necessary  either  before  or  after  labour  ?  This  practice 
has  been  in  the  past  and,  indeed,  is  still  adopted  by  many  com- 
petent authorities.  It  is,  however,  an  operation — for  it  is  right 
to  consider  it  such — to  which  a  very  definite  risk  is  attached, 
the  risk  of  introducing  instead  of  removing  septic  organisms. 
Consequently,  it  is  a  practice  which  should  not  be  adopted  unless 
it  can  be  clearly  shown  that  the  danger  of  omitting  it  is  greater 
than  the  danger  of  adopting  it.  The  study  of  the  bacteriology  of 
the  vagina  has  shown,  and  clinical  facts  have  clearly  demonstrated, 


152  OBSTETRICAL  ASEPSIS  AND  ANTISEPSIS 

that  this  is  not  so.  When  a  vaginal  douche  is  regarded  as  a 
preliminary  essential  to  operation,  and  as  a  procedure  which  must 
be  carried  out  thoroughly  and  carefully,  the  attendant  risk  of 
introducing  septic  organisms  is  minimised.  But,  when  the  ad- 
ministration of  a  vaginal  douche  is  regarded  as  a  matter  of 
routine — which  must  be  done  in  every  case,  and  of  the  efficacy 
of  which  there  is  considerable  doubt,  and  especially  when  it  is  en- 
trusted to  a  more  or  less  competent  nurse-tender  to  carry  out,  the 
possibility  of  the  infection  of  the  patient  is  very  much  increased. 

We  may  answer  definitely  in  a  few  words  the  question  which 
we  have  asked.  The  use  of  a  routine  vaginal  douche  in  normal 
cases  is  not  only  unnecessary,  but  dangerous.  It  is  a  practice 
which  cannot  be  too  strongly  condemned,  and  which,  we  trust, 
will  rapidly  fall  into  the  same  oblivion  in  private  practice  into 
which  it  has  already  fallen  in  well-conducted  maternity  hospitals. 

When  any  operation  has  to  be  performed  which  necessitates 
the  passing  of  the  hand  or  of  instruments  into  the  uterine  cavity 
the  cleansing  of  the  external  genitals  must  be  still  more  care- 
fully performed.  In  such  cases  the  obstetrician  must  not  trust 
to  the  nurse,  but  perform  this  duty  himself  as  an  immediate  pre- 
liminary to  the  operation.  In  addition  to  the  external  disinfec- 
tion, it  is  also  well  to  thoroughly  wash  out  the  vagina,  with  the 
object  of  removing  all  discharge,  blood-clots,  etc.,  which  may 
have  collected  there.  The  necessity  for  this  may  be  questioned, 
in  view  of  what  we  know  of  the  bacteriology  of  the  vagina.  The 
answer  is  shortly  this  : — The  vaginal  discharge  may  contain  facul- 
tative saprophytes,  or  even  actual  saprophytes  which  have  gained 
access  in  the  air.  If  these  are  carried  into  the  uterus,  and  there 
find  a  suitable  nidus,  sapraemic  infection  will  result.  This  is 
particularly  likely  to  occur  in  cases  of  the  application  of  the 
forceps  when  labour  has  been  prolonged.  In  these  cases,  the 
liquor  amnii  lies,  possibly  for  many  hours,  in  the  vagina,  and 
decomposes  under  the  influence  of  air-borne  saprophytes.  Con- 
sequently, a  preliminary  douche  is  advisable.  Further,  in  normal 
cases,  all  movement  through  the  vagina  is  in  a  downward 
direction,  and  so  tends  to  prevent  the  upward  passage  of  micro- 
organisms. When,  however,  the  hands  or  instruments  are  passed 
upwards  into  the  uterus  the  reverse  is  the  case,  and  any  decom- 
posing material  in  the  vagina  is  directly  carried  upwards. 

The  most  suitable  fluid  with  which  to  douche  out  the  vagina 
or  uterus  is  in  all  probability  sterilised  water,  if  it  can  be  ob- 
tained. It  is  very  improbable  that  antiseptic  solutions  have  any 
direct  germicidal  effect  on  bacteria  which  may  be  present,  inas- 
much as  bacteria  are  not  exposed  to  their  action  for  a  sufficient 
period  to  be  destroyed  by  the  weak  solution  which  we  are  com- 
pelled to  use.  Vaginal  douches  in  all  probability  produce  vaginal 
asepsis,  not  by  killing  the  bacteria  present,  but  by  sweeping  them 
away  mechanically  in  the  stream  of  water.  However,  in  private 
practice  it  is  seldom  or  never  possible  to  obtain  sterilised  water, 


VAGINAL  DOUCHING  153 

and,  consequently,  we  must  use  the  next  best  substitute,  which 
will  be  furnished  by  water  to  which  an  antiseptic  has  been  added 
with  the  object  of  sterilising  it.  For  general  use,  a  one  per  cent, 
solution  of  lysol,  or  a  1  in  320  (i.e.,  \  oz.  to  a  gallon)  solution  of 
creolin  is  perhaps  the  most  suitable.  Lysol  possesses  the  undoubted 
advantage  of  containing  a  quantity  of  soap  which  increases  its 
cleansing  action,  and  which  by  its  lubricating  quality  facilitates 
any  intravaginal  or  intra-uterine  manipulations.  On  the  other 
hand,  lysol  is  apt  to  cause  unpleasant  irritation  of  the  skin  and 
mucous  membrane  of  the  patient.  If  creolin  is  used,  the  necessary 
quantity  must  be  first  added  to  cold  water,  and  then  boiling  water 
added  to  this,  as  it  does  not  mix  well  with  hot  water. 

The  use  of  corrosive  sublimate  solution  for  douching  purposes 
is  not  to  be  recommended.  In  the  first  place,  even  in  very  weak 
solution  it  is  occasionally  attended  with  unpleasant  consequences, 
as  it  affects  different  patients  in  different  degrees  of  severity. 
Fatal  consequences  have  followed  the  injection  of  a  quart  of 
corrosive  sublimate  solution  of  a  strength  of  1  in  1,000."  Its  use 
is  especially  dangerous  in  the  case  of  patients  suffering  from 
Bright's  disease  or  in  those  who  have  had  attacks  of  haemorrhage, 
or  who  have  extensive  laceration  of  the  vagina  (Ribemont- 
Dessaignes).  Further,  it  is  unreliable  as  an  antiseptic,  as  it  is 
decomposed  by  albumin  forming  an  insoluble  albuminate  of 
mercury,  and,  if  this  decomposition  is  prevented  by  the  addition 
of  tartaric  acid,  as  is  usually  the  case,  the  toxic  effect  of  the 
douche  is  increased.  Also,  corrosive  sublimate  has  the  un- 
pleasant property  of  constringing  the  tissues  with  which  it  comes 
into  contact,  and  so  increasing  their  rigidity  and  liability  to 
laceration  during  labour.  If,  for  any  reason,  corrosive  sublimate 
is  used  for  douching  purposes,  a  solution  of  1  in  5,000  is  of  suffi- 
cient strength,  and  such  a  solution  is  said  to  have  the  same 
bactericidal  effect  as  has  a  solution  of  1  in  1,000  (Tarnier). 

Carbolic  acid  is  also  unsuitable  for  use,  as  its  toxicity  is  greater 
in  comparison  to  its  germicidal  power  than  is  the  toxicity  of 
either  creolin  or  tysol.  It  also  occasionally  causes  an  erythe- 
matous eruption  of  the  skin  and  mucous  membrane  with  which 
it  comes  in  contact.  If  it  is  used,  the  strength  of  the  solution 
should  not  exceed  two  per  cent. 

A  vaginal  douche  is  administered  as  follows  : — The  patient 
is  placed  on  the  left  side,  with  her  buttocks  projecting  well 
over  the  edge  of  the  bed.  Beneath  her,  is  placed  a  small 
mackintosh  of  sufficient  size  to  extend  beyond  her  into  the  bed, 
where  it  ought  to  pass  over  a  pillow  or  a  folded  sheet,  in  order  to 
prevent  the  water  from  running  in  the  wrong  direction,  while  it 
hangs  over  the  edge  of  the  bed  as  a  valance,  and  so  serves  to 
conduct  the  water  into  a  bath  placed  to  catch  it.  The  douching- 
fluid  is  placed  in  a  jug  or  douche-can,  from  which  it  can  be  drawn 

*  '  Death  from  a  Single  Vaginal  Douche,'  by  G.  de  N.  Hough,  Boston  Med. 
and  Surg.  Journ.,  April  9,  1903,  p.  393. 


154  OBSTETRICAL  ASEPSIS  AND  ANTISEPSIS 

by  a  syphon-douche  in  the  manner  subsequently  described,  and 
which  is  placed  at  the  necessary  height.  The  external  genitals 
are  first  thoroughly  washed  and  disinfected.  A  glass  nozzle,  with 
several  apertures  at  the  end  for  the  escape  of  the  fluid,  is  then 
fixed  to  the  end  of  the  tube  ;  the  doctor  or  nurse,  as  the  case 
may  be,  stands  or,  better,  sits  on  a  low  stool  beside  the  patient, 
and  holding  the  nozzle  in  the  right  hand,  passes  two  fingers  of 
the  left  hand  into  the  vagina,  and  draws  back  the  perinaeum. 
The  nozzle  is  then  introduced,  and  passed  at  once  to  the  top  of 
the  vagina,  in  order  that  the  stream  may  flow  downwards  through 
the  vagina,  and  not  upwards.  While  the  fluid  flows,  the  fingers 
distend  the  vaginal  walls,  in  order  to  ensure  that  no  folds  exist  in 
which  discharge  can  remain.  The  usual  amount  of  fluid  which 
is  used  is  about  half  a  gallon. 

If  a  uterine  douche  is  to  be  administered,  it  is  preferable  to 
place  the  patient  in  the  cross-bed  position,  her  buttocks  project- 
ing over  the  edge  of  the  bed  and  the  mackintosh  arranged  as 
before.  A  vaginal  douche  is  given  in  the  manner  described, 
and  then  the  glass  nozzle  is  removed  and  a  Bozemann's  return 
catheter  substituted.  Under  the  guidance  of  the  fingers,  the 
catheter  is  introduced  into  the  uterus,  and  passed  cautiously  up- 
wards as  far  as  it  will  go.  The  tip  of  the  catheter  is  moved 
gently  from  side  to  side  in  order  to  wash  out  the  entire  cavity. 
If  the  return  pipe  becomes  blocked  by  a  clot  or  debris,  the  catheter 
must  be  at  once  removed  and  the  pipe  cleared. 


I 


CHAPTER  II 
THE  OBSTETRICAL  ARMAMENTARIUM 

Antiseptics — Drugs — Instruments,  for  General  Use,  for  Special  Operations — 
Contents  of  the  Obstetrical  Bag. 

The  armamentarium  of  the  obstetrician  should  be  as  uncompli- 
cated and  as  small  as  is  consistent  with  the  requirements  of 
modern  obstetrics,  inasmuch  as  portability  is  .a  most  necessary 
quality.  At  the  same  time,  it  must  also  be  complete.  An 
obstetrician  has  frequently  to  attend  patients  at  a  considerable 
distance  from  his  residence,  and,  as  some  obstetrical  complica- 
tions are  sudden  in  their  occurrence  and  urgent  in  their  demand 
for  treatment,  it  is  never  safe  to  rely  on  the  possibility  of  sending 
for  the  necessary  instruments  or  drugs  when  they  are  required. 
They  must  rather  be  always  at  hand,  or  otherwise  valuable  time 
may  be  wasted  and  perhaps  life  lost.  In  the  following  chapter 
we  propose  to  enumerate  the  various  components  of  an  obstet- 
rician's armamentarium,  mentioning  the  instruments  and  drugs 
which  should  be  always  at  hand  during  the  conduction  of  a  case, 
as  well  as  those  which  may  occasionally  be  required,  but  which 
it  is  not  necessary  to  have  always  within  immediate  reach. 

Antiseptics. — As  we  have  seen  in  the  previous  chapter, 
antiseptics  are  required  for  the  disinfection  of  the  hands  of  the 
obstetrician  and  the  skin  of  the  patient,  and  for  use  in  vaginal 
and  uterine  douches.  For  these  purposes,  two  antiseptics  are 
sufficient — corrosive  sublimate  and  lysol  or  creolin.  Corrosive 
sublimate  is  most  readily  carried  in  the  form  of  tablets,  one  of 
which  added  to  a  pint  of  water  makes  a  solution  of  the  strength 
of  i  in  i  ,000.  The  other  two  antiseptics  are  carried  in  their 
full  strength. 

In  certain  septic  conditions  of  the  genital  tract,  it  may  be 
necessary  to  use  some  antiseptic  in  a  form  which  will  enable  it  to 
be  brought  into  prolonged  contact  with  the  septic  area.  This  is 
particularly  the  case  in  puerperal  ulcers,  septic  endometritis,  and 
such  conditions.  The  most  useful  antiseptic  for  this  purpose 
is  iodoform,  a  substance  which  can  be  introduced  into  the  genital 
passages  as  a  powder,  in  the  form  of  a  pencil  or  bougie,  or  on 

i55 


156  THE  OBSTETRICAL  ARMAMENTARIUM 

gauze.  The  powder  can  be  carried  in  a  small  dusting-pot  with 
a  screw  cover,  to  prevent  the  escape  of  the  iodoform  or  the 
entrance  of  dirt.  Iodoform  bougies  are  but  rarely  required,  as 
their  place  has  been  largely  taken  by  iodoform  gauze.  The 
author  does  not  recommend  their  use.  If  required,  they  can  be 
carried  in  a  sterilised  bottle  with  a  closely-fitting  stopper.  Iodo- 
form gauze,  on  the  other  hand,  is  a  most  valuable  substance,  and 
furnishes  an  excellent  method  of  obtaining  the  germicidal  action 
of  iodoform.  It  is  used  not  alone  for  disinfecting  septic  surfaces, 
but  also  for  plugging  the  vagina  and  uterus  in  cases  of  haemor- 
rhage, etc.,  as  in  such  cases  the  use  of  aseptic  gauze  is  inad- 
visable on  account  of  the  danger  of  saprophytic  decomposition. 
The  form  of  gauze  most  suited  for  obstetrical  work  is  known  as 
moist  gauze,  and  contains  about  ten  per  cent,  of  iodoform.  It  is 
usually  packed  in  boxes  or  jars  containing  six  yards.  These 
pieces  are  too  wide  for  tamponing  purposes,  and  should  be  cut 
into  strips  of  two  or  three  inches  in  width.  These  are  then  rolled 
as  a  bandage,  and  are  ready  for  use  when  required.  Considerable 
doubt  has  been  expressed  as  to  the  germicidal  power  of  iodoform, 
as,  experimentally,  it  appears  to  have  little  or  no  effect  on  staphy- 
lococci or  streptococci  in  culture-tubes  There  is,  however,  little 
doubt  that,  practically,  as  applied  to  wounds,  iodoform  has  a  con- 
siderable germicidal  effect,  or,  at  any  rate,  a  considerable  power 
of  preventing  the  effects  of  germ  infection.  This  difference  in 
its  behaviour  is  accounted  for  on  the  ground  that  iodoform,  to 
develop  its  germicidal  effect,  requires  to  be  in  the  presence  of 
albumin.  It  is  also  said  that  iodoform  does  not  so  much  destroy 
bacteria  as  transform  their  toxins  into  combinations  with  iodine 
which  are  non-toxic  (Stchegoleff).*  Whatever  may  be  its  actual 
mode  of  action,  the  beneficial  effect  of  iodoform  in  suppurative  or 
saprsemic  conditions  is  undeniable. 

Drugs. — The  drugs  which  must  be  carried  by  an  obstetrician 
are  few  in  number,  and  only  include  such  as  are  of  routine  use  or 
are  liable  to  be  required  in  an  emergency.  The  following  list  will 
as  a  rule  be  found  to  be  sufficient  : — 

(i)  Ergot. — This  may  be  carried  either  as  the  liquid  extract,  for 
administration  by  the  mouth  or  hypodermically,  or  as  citrate  of 
ergotinin  for  hypodermic  administration.  The  pharmacopceial  dose 
of  the  former  preparation  is  ten  to  thirty  minims  by  the  mouth, 
and  is  valueless  for  obstetrical  purposes — i.e.,  as  an  oxytoccic  or 
promoter  of  uterine  contractions.  For  this  purpose,  up  to  two 
drachms  may  be  given  by  the  mouth,  and  up  to  half  a  drachm 
hypodermically.  The  pharmacopoeial  preparation  is  notoriously 
unreliable,  but  the  preparation  known  as  Squibb's  liquid  extract 
of  ergot  may  be  regarded  as  trustworthy  if  it  has  not  been  kept  for 
too  long.  Up  to  ^T  grain  of  the  citrate  of  ergotinin  may  be  given 
hypodermically. 

*  Arch,  de  Med.  Experiment.,  November,  1894. 


OBSTETRICAL  INSTRUMENTS  157 

(2)  Chloroform. — This  is  required  for  inducing  anaesthesia.  A 
four-ounce  drop-bottle  should  be  carried. 

(3)  Strychnine.— This  may  be  required  in  cases  of  syncope  from 
haemorrhage  or  other  cause.  It  is  most  easily  carried  as  the 
sulphate  of  strychnine,  made  up  in  tablets  for  hypodermic  ad- 
ministration, and  containing  TiF  grain.  Up  to  J^  grain  may  be 
administered  at  a  time. 

(4)  Ether.  —  This  may  also  be  required  in  cases  of  syncope.  It 
is  administered  hypodermically  in  doses  of  twenty  to  forty  minims. 
An  ounce  or  so  of  it  should  be  carried  in  a  stoppered  bottle. 

(5)  Tincture  of  Opium  and  Morphia. — Both  these  drugs  should 
be  carried,  as  they  are  constantly  required  for  their  sedative  or 
hypnotic  effect,  and  morphia  may  also  be  required  in  cases  of 
eclampsia.  An  ounce  of  the  former  in  a  stoppered  bottle  and 
tablets  containing  a  third  of  a  grain  of  the  latter  for  hypodermic 
administration,  are  the  easiest  method  of  carrying  them. 

The  foregoing  are  the  only  drugs  which  should  be  habitually 
carried.    Any  others  can  be  obtained  specially  if  they  are  wanted. 

Instruments. — In  discussing  the  various  instruments  which 
are  required  by  the  obstetrician  we  propose  to  divide  them  into 
two  classes : — 

(A)  Instruments  which  are  required  for  general  obstetrical 

purposes  or  whose  use  is  common  to  the  majority  of 
operations. 

(B)  Instruments  which  are  required  for  the  performance  of 

special  operations. 

(A)  General  Instruments. — The  instruments  or  appliances  which 
are  required  for  general  purposes  or  whose  use  is  common  to  the 
majority  of  operations  are  as  follows  : — 

(1)  A  Syphon  Douche. — This  appliance  is  designed  to  take  the 
place  in  private  practice  of  the  douche-tin,  which  is  more  generally 
used  in  hospitals.  It  is  a  portable,  easily-cleaned,  and  most 
efficient  means  of  administering  a  vaginal  or  uterine  douche,  and 
has,  we  trust,  entirely  supplanted  that  dangerous  and  inefficient 
implement,  a  Higginson's  enema  syringe.  The  construction  of  a 
syphon  douche  will  be  readily  understood  from  the  illustration 
(v.  Fig.  102).  It  is  composed  of  a  rubber  tube  about  six  feet  in 
length,  without  valves  of  any  kind.  At  one  end,  it  has  got  a 
sinker,  which  keeps  it  immersed  in  the  fluid  used ;  a  little  further 
up  the  tube  is  encased  in  a  movable  horseshoe-shaped  guard  of 
vulcanite,  which  fits  over  the  edge  of  the  jug  and  prevents  the 
tube  from  kinking.  Halfway  down  the  tube,  there  is  a  ball-shaped 
expansion,  and  a  little  further  on  there  may  or  may  not  be  a  tap. 
It  is  completed  at  the  other  end  by  a  glass  nozzle.  To  use  the 
douche,  the  sinker  is  immersed  in  the  fluid,  and  the  vulcanite 
guard  adapted  to  the  depth  of  the  jug,  which  is  then  placed 
upon  the  stand.  The  ball  is  compressed  with  one  hand,  and  the 
tube  then  nipped  between   the  nozzle  and  the  ball.       By    this 


i58 


THE  OBSTETRICAL  ARMAMENTARIUM 


means,  when  the  ball  is  released,  water  is  drawn  into  it  from  the 
jug.  This  usually  is  sufficient,  and  the  water  will  continue  to  run, 
upon  the  principle  of  a  syphon.  If  it  does  not,  it  is  only  neces- 
sary to  repeat  the  previous  manipulation. 

Its  advantages  over  a  Higginson's  syringe  are  at  once  apparent. 
The  latter  has  got  two  valves,  which  are  seldom  perfectly 
efficient.  The  result  is  that  there  is  usually  a  slight  amount  of 
indraw  through  the  nozzle,  and  consequently  vaginal  discharge, 
etc.,  tends  to  find  its  way  into  the  ball,  with  the  result  that  the 
difficulty  of  keeping  it  sterile  is  very  great.  Further,  the  flow 
of  water  from  it  is  intermittent,  and  it  requires  the  use  of  both 
hands,  one  holding  the  nozzle  in  position,  the  other  compressing 
the  ball.  Lastly,  the  fact  that  an  enema  syringe  is  primarily 
intended,  and  is  used  for  the  administration  of  enemata,  renders 
it  probable  that  a  single  syringe  will  be  used  for  both  the  rectum 
and  the  vagina — a  most  dangerous  practice.  A  syphon  douche  can 
be  sterilised  by  allowing  it  to  soak  for  some  hours  in  a  i  in  500 
solution  of  corrosive  sublimate,  if  the  metal  sinker  and  the  tap 


Fig.  102. — A  Syphon  Douche.  . 

are  first  removed.     It  should  then  be  carried  in  a  sterilised  water- 
proof bag. 

(2)  An  Enema  Syringe. — This  may  be  occasionally  required  for 
the  administration  of  enemata,  and  must  not  be  used  for  any 
other  purpose.  Higginson's  syringe  is  the  form  which  is  generally 
used.  It  should  be  carried  in  a  small  bag,  to  prevent  it  from 
coming  into  contact  with  other  instruments. 

(3)  A  Female  Catheter. — A  metal  catheter  of  the  form  shown  is 
the  most  serviceable.  It  is  readily  sterilised  by  boiling,  and  can- 
not be  broken.  The  percentage  of  cases  in  which  it  is  necessary 
to  empty  the  bladder,  and  in  which  such  a  catheter  cannot  be 
introduced,  is  extremely  small,  and  for  such  cases  a  new  gum- 
elastic  catheter  may  be  carried,  but  as  it  cannot  be  easily  sterilised, 
it  must  not  be  used  a  second  time. 


OBSTETRICAL  INSTRUMENTS  159 

(4)  Vaginal  and  Uterine  Douche  Tubes. — -A  glass  nozzle  six  inches 
in  length  and  pierced  at  the  top  with  several  holes  is  the  best 
form  of  tube  for  vaginal  douching.  It  can  be  sterilised  by  boiling. 
Two  or  three  should  be  carried,  as  they  are  liable  to  get  broken. 
For  uterine  douching,  a  return  catheter  is,  necessary — that  is,  one 
which  not  only  carries  the  water  into  the  uterine  cavity,  but  also 
provides  a  means  for  the  escape  of  the  fluid.  The  best  form  is, 
perhaps,  that  devised  by  Bozemann.  It  is  made  of  metal,  and 
can  be  taken  apart  for  cleansing  purposes.  Two  sizes  should  be 
carried.  A  large  size  for  post-partum  douching,  and  a  smaller 
size  for  use  in  cases  of  abortion,  etc. 

(5)  A  Hypodermic  Syringe. — One  of  the  numerous  forms  which 
permit  of  sterilisation  should  be  used. 

(6)  A  Mucus  Aspirator. — This  is  required  for  removing  mucus 
from  the  throat  of  the  infant,  in  cases  where  premature  efforts  at 


SE5^EES133*I3£?vpSs 


Fig.  103.  — Female  Catheter. 

inspiration  have  been  made.  Ribemont-Dessaignes  devised  a 
special  instrument  for  this  purpose,  composed  of  a  tube  with  a 
curve  corresponding  to  the  respiratory  passages,  and  through 
which  suction  is  obtained  by  the  attachment  of  a  rubber  bag 
similar  to  that  of  a  ball  enema  syringe  or  by  the  mouth  of  the 
operator  applied  directly.*  A  male  metal  No.  3  catheter  answers 
the  same  purpose,  and  is  more  generally  used. 

(7)  A  Pair  of  Surgical  Scissors. 

(8)  A  Good  A r ail-Brush. 

(9)  Chloroform  Inhalers. — It  is  usually  advisable  to  carry  two 
forms  of  chloroform  inhaler,  one  for  obtaining  obstetrical,  and  the 
other  for  obtaining  surgical  anaesthesia.  For  the  first  purpose, 
Murphy's  inhaler  is  best.  It  will  be  subsequently  described. 
For  the  second  purpose,  Schimmelbusch's  mask  or  other  similar 
form  of  mask  is  most  suitable. 

(B)  Special  Instruments. — The  instruments  or  appliances 
which  are  required  for  the  performance  of  special  operations  are 
as  follows  : — 

( 1 )  The  Induction  of  L  abour  and  Dilatation  or  Incision  of  the  Cervix. — 
(a)  Gum-elastic  bougies ;  (b)  Champetier  de  Ribes'  or  Barnes' 
hydrostatic  dilators,  or  sea-tangle  tents  ;    (c)   Hegar's  dilators ; 

*  '  Recherches  sur  1' insufflation  des  nouveau-nes  et  description  d'un  nouveau 
tube  laryngien,'  Progres  Medical,  1878. 


160  THE  OBSTETRICAL  ARMAMENTARIUM 

(d)  American  forceps;  (e)  long-handled  and  blunt-pointed  scissors; 
(/)  vaginal  speculum  ;  (g)  appliances  for  suturing  as  below. 

(2)  The  Application  of  Forceps. — A  pair  of  long  axis-traction 
forceps — Neville's,  Milne  Murray's,  or  Tarnier's. 

(3)  Extraction  in  Obstructed  Breech  Cases.  —  A  porte-fillet  or 
No.  10  gum-elastic  catheter  with  stilette. 

(4)  Craniotomy. — (a)  A  perforator — Simpson's  or  Naegele's  ;  (b)  a 
cranioclast  —  Braun's ;  or  better,  a  combined  cranioclast  and 
cephalotribe — Winter's  modification  of  Auvard's. 

(5)  Embryotomy. — (a)  Braun's  blunt  hook  ;  (b)  a  pair  of  stout, 
long-handled  and  sharp-pointed  scissors. 

(6)  Celiotomy  and  Hysterectomy. — (a)  Two  scalpels  ;  (b)  a  dozen 
clip-forceps  ;  (c)  three  pairs  of  scissors,  one  sharp-pointed,  one 
blunt-pointed,  and  one  curved  on  the  flat ;  (d)  retractors  ;  (e)  four 
or  five  long,  straight  and  curved,  narrow-bladed  clamp-forceps, 
and  four  or  five  stouter  forceps  of  various  shapes  ;  (/)  needles, 
needle-holders,  and  suture  materials ;  (g)  two  short  and  two  long 
dissecting  forceps  with  sharp  teeth  ;  (h)  three  or  four  dozen  gauze 
sponges. 

(7)  Symphysiotomy. — (a)  Two  scalpels  ;  (b)  two  pairs  of  scissors  ; 
(c)  two  lateral  retractors  ;  (d)  whole  curved  needles  of  different 
sizes ;  (e)  needle-holder ;  (/)  a  dozen  clip-forceps ;  (g)  several 
straight  and  curved  narrow-bladed  clamps  ;  (h)  dissecting  forceps 
with  teeth  ;  (i)  suture  materials  ;  (j)  iodoform  gauze ;  (k)  the 
usual  sponges  and  dressings.  In  addition,  the  following,  though 
not  absolutely  necessary,  are  often  of  great  assistance  :  (/)  A 
special  knife  for  dividing  the  symphysis  ;  (m)  a  bistoury  with  a 
short  strong  blade,  thinner  at  the  edges  than  in  the  middle  ; 
(n)  Faraboeuf's  grooved  sound ;  (0)  a  registering  separator  for 
separating  and  measuring  the  distance  between  the  pubic  bones. 

(8)  Suture  of  Perineal  Lacerations,  etc. — (a)  Needle-holder — 
Martin's   or   other   form  ;  (b)   whole   curved   needles — Martin's ; 

(c)  sterilised  silk,  silkworm  gut,  or  cat-gut. 

(9)  Suture  of  Cervix. — In  addition  to  the  foregoing — (a)  posterior 
vaginal  speculum  ;  (b)  two  American  forceps. 

(10)  Tamponade  of  the  Vagina  and  Uterus. — (a)  Iodoform  gauze; 
(b)    cotton  -  wool  ;    (c)    long    narrow-bladed    plugging    forceps  ; 

(d)  American  forceps  and  posterior  vaginal  speculum. 

(11)  Curetting. — (a)  Two  or  three  curettes  —  Rheinstadter's, 
Sims',  and  Hegar's  ;  (b)  American  forceps. 

(12)  Infusion  of  Saline  Solution. — (a)  A  blunt-pointed  metal  nozzle 
for  introduction  into  vein  ;  (b)  a  sharp-pointed  metal  nozzle  for 
introduction  into  cellular  tissue. 

The  foregoing  is  a  fairly  full  list  of  the  instruments  and  ap- 
pliances which  may  be  required  to  meet  any  obstetrical  emergency. 
We  must  now  select  from  amongst  them  those  which  should  be 
habitually  carried  in  the  obstetrician's  bag.    They  are  as  follows  : — 

(1)  A  syphon  douche,  two  glass  nozzles,  and  a  large  and  small 
Bozemann's  catheter. 


OBSTETRICAL  INSTRUMENTS  161 

(2)  An  enema  syringe. 

(3)  A  female  metal  catheter,  a  male  No.  3  metal  catheter,  and 
a  male  No.  10  gum  elastic  catheter. 

(4)  A  pair  of  surgical  scissors,  and  a  pair  of  stout  long-handled 
and  blunt-pointed  scissors. 

(5)  A  good  nail-brush. 

(6)  Murphy's  chloroform  inhaler,  and  any  pattern  of  chloroform 
mask. 

(7)  An  axis-traction  forceps. 

(8)  Needles,  needle-holder,  silk,  silkworm  gut,  and  catgut. 

(9)  A  blunt  flushing  curette. 

(10)  A  sharp-pointed  metal  canula  for  intracellular  infusion. 

(11)  Iodoform  gauze  and  a  plugging  forceps. 

All  these  instruments  and  appliances  can,  together  with  the 
necessary  drugs  and  antiseptics  which  have  been  mentioned,  be 
carried  in  an  obstetrical  bag  of  the  usual  size. 


CHAPTER  III 
OBSTETRICAL  DIAGNOSIS 

Methods  of  Examination  —  The  History  of  the  Patient  —  Inspection  — 
Abdominal  Palpation,  the  Diagnosis  of  Pregnancy,  of  the  Presentation 
and  Position  of  the  Foetus,  of  the  Course  of  Labour,  of  the  Presence 
of  Complications  ;  Different  Grips — Vaginal  Examination — Auscultation  ; 
Maternal  Sounds  ;  Fcetal  Sounds — Pelvimetry;  External  Measurements ; 
Internal  Measurements. 

In  the  following  chapter,  we  intend  to  discuss  the  various  methods 
by  which  we  can  obtain  the  necessary  information  regarding  the 
patient  during  pregnancy,  labour,  and  the  puerperium.  We  shall 
only  discuss  methods,  and  the  information  each  one  furnishes  ;  the 
application  of  these  methods  to  the  diagnosis  of  obstetrical  con- 
ditions will  be  discussed  in  another  place. 

The  different  methods  of  examining  the  patient  are  as  follows  : — ■ 
I.  Questioning,  with  the  object  of  eliciting  her  previous 

medical  history  and  symptoms. 
II.  Inspection. 

III.  Abdominal  palpation. 

IV.  Vaginal  examination. 
V.  Auscultation. 

VI.   Pelvimetry. 

THE  HISTORY  OF  THE  PATIENT 

The  information,  which  must  be  elicited  regarding  the  history 

and  symptoms  of  the  patient  differs,  to  some  extent,  according  as 

we  are  dealing  with  a  patient,  during  pregnancy  or  during  labour. 

During  pregnancy  the  following  information  must  be  obtained: — 

( i )  Date  of  last  menstruation  ;  date  of  quickening  ;  date 

at  which  the  movements  of  the  foetus  were  last  felt. 

(2)  Changes  noticed  in  the  size  and  appearance  of  abdomen 

and  breasts. 

(3)  Condition  of  general  health  previous  to  pregnancy  and 

during  pregnancy. 

(4)  Number  and  nature  of  previous  pregnancies,  if  any. 

(5)  Nature  of  previous  labours.     Are  the  children  alive  or 

dead  ?    If  dead,  did  they  die  prior  to  or  during  labour 
or  after  delivery,  and  what  was  the  cause  of  death  ? 
162 


INSPECTION  163 

(6)  Condition  of  urinary  system.     Amount  of  urine  passed 

daily.     Presence  of  any  urinary  trouble,  such  as  too 
frequent  micturition. 

(7)  Condition   of  digestive  system.      Presence  of  nausea, 

vomiting,  loss  of  appetite,  indigestion,  constipation, 
diarrhoea. 

(8)  History  of  any  organic  disease. 

(9)  Presence  of   any  abnormal    condition  of    the   genital 

organs — e.g.,  vaginal  discharge,  pruritus  vulvae,   pro- 
lapse of  vagina,  etc. 
During  labour  answers  to  the  following  information  must  also 
be  obtained  : — 

(1)  When  did  the  uterine  contractions  commence  ? 

(2)  Have  the  membranes  ruptured  ?     If  so,  how  long  ? 

(3)  Is  there  any  inclination  to  '  bear  down  ' — i.e.,  to  exert 

the  voluntary  muscles  of  labour  ? 

INSPECTION 

A  general  inspection  of  the  patient  is  made  with  the  object  of 
determining  the  presence  of  the  usual  appearances  of  pregnancy, 
of  any  obvious  signs  of  ill-health,  of  abdominal  tumours,  or  any 
marked  deformity  which  could  give  rise  to  difficulties  during 
labour. 

The  usual  appearances  of  pregnancy  are  present  to  a  varying 
degree  in  correspondence  with  the  period  of  pregnancy,  and  are 
as  follows  : — 

(1)  The  face  : — Alterations  in  complexion  and  aspect. 

(2)  The  breasts: — Alterations  in  size,  shape,  and  appear- 

ance. 

(3)  The  abdomen  : — Alterations  in  size,  shape,  and  appear- 

ance. 

(4)  The  vulva  and  vagina  : — Alterations  in  appearance. 
The  nature  of  these  alterations  will  be  dealt  with  later. 

An  obvious  indication  of  ill-health  is  furnished  by  an  appearance 
of  undue  emaciation  or  cachexia,  or  by  the  presence  of  anaemia, 
oedema,  jaundice,  or  glandular  enlargements. 

The  presence  of  abdominal  tumours  may  be  suggested  by  the 
enlargement  of  the  abdomen  out  of  proportion  to  the  age  of  the 
pregnancy,  and  perhaps  by  the  irregular  and  asymmetrical 
character  of  the  enlargement. 

The  existence  of  marked  pelvic  deformity  may  be  suggested  by 
the  following  conditions  : — 

(1)  Undue  prominence  of  the  abdomen,  or  a  pendulous 

abdomen. 

(2)  Diminutive  stature. 

(3)  Curvature  of  the  spine — kyphosis,  lordosis,  or  scoliosis. 

(4)  Crooked  legs,  legs  of  unequal  length,   or  absence  of 

one  leg. 


164  OBSTETRICAL  DIAGNOSIS 


ABDOMINAL  PALPATION 

By  abdominal  palpation  is  meant  the  examination  of  the  organs 
contained  in  the  abdominal  cavity  by  the  hands  applied  directly 
to  the  abdominal  walls.  It  is  one  of  the  most  important  methods 
of  examining  a  pregnant  or  parturient  woman,  inasmuch  as  it 
furnishes  information  which  can  be  obtained  in  no  other  way,  and 
as  it  does  so  without  causing  any  risk  to  the  patient  and  with  a 
minimum  of  discomfort.  In  both  these  respects,  it  compares  very 
favourably  with  vaginal  examination,  which  can  never  be  entirely 
divested  of  danger,  no  matter  how  many  precautions  are  taken, 
and  which,  moreover,  often  causes  to  the  patient  not  only  dis- 
comfort, but  even  actual  pain.  At  all  times,  in  the  practice 
of  obstetrics,  we  endeavour  to  replace  internal  manipulations  by 
external  manipulations,  and,  as  we  shall  see,  we  can  succeed  in 
attaining  this  object  to  a  very  marked  degree  by  the  adoption  of 
abdominal  palpation  instead  of  vaginal  examination.  Accord- 
ingly, a  knowledge  of  the  information  which  abdominal  palpation 
will  afford,  and  a  sufficient  degree  of  skill  in  carrying  it  out,  are 
essential  to  the  practice  of  obstetrics. 

It  is  curious,  that,  in  spite  of  the  fact  that  the  value  of  abdominal 
palpation  has  been  recognised  for  close  on  a  hundred  years,  it  is 
only  quite  recently  that  the  necessity  for  its  practice  has  been 
insisted  upon  by  obstetrical  writers  with  any  approach  to 
unanimity,  even  though  many  of  these  writers  have  recognised  the 
close  connection  between  repeated  vaginal  examinations  and  the 
occurrence  of  septic  infection.  So  far  from  abdominal  palpation 
being  a  product  of  the  closing  years  of  the  nineteenth  century — 
as  a  perusal  of  the  obstetrical  literature  of  this  country  would 
lead  one  to  suppose,  directions  as  to  the  method  of  performing  it, 
and  particulars  of  the  information  which  it  might  be  expected  to 
yield,  were  published  by  Wigand*  in  1812,  by  Schmittt  in  1829, 
and  by  Hohl;[  in  1834.  Indeed,  the  last-mentioned  author  de- 
scribed the  facts  which  can  be  ascertained  by  abdominal  palpation 
as  clearly  and  as  fully  as  it  is  possible  to  do  at  the  present  day. 
In  spite  of  these  writings,  however,  abdominal  palpation  was  not 
generally  recognised  to  be  of  value  until  the  last  quarter  of  the 
nineteenth  century,  when  Crede  and  Leopold  in  Germany, Pinard 
in  France, §  and  Macan,  Neville,  and  Smyly  in  Dublin,  drew  the 
attention  of  obstetricians  to  its  immense  practical  importance.  At 
the  present  day,  its  position  in  obstetrics  is  generally  recognised, 
and  the  methods  of  performing  it  are  universally  taught  in  all 
large  obstetrical  clinics. 

*  '  De  la  version  par  manoeuvres  externes  et  de  1' extraction  du  foetus  par  les 
pieds.' 

+  '  Gesammte  obstetrische  Schriften.'     Wien,  1820-1828. 

I  'Die  geburtschulfliche  Exploration,'  vol.  ii.,  p.  144.     1834. 

§  '  Traite  du  palper  abdominal,  au  point  de  vue  obstetrical.'     Paris,  1878. 


ABDOMINAL  PALPATION  165 

Accordingly,  on  account  of  the  importance  of  the  technique  of 
abdominal  palpation,  we  shall  describe  the  method  of  per- 
forming it — 

(1)  With  the  object  of  diagnosing  the  existence  of  preg- 

nancy. 

(2)  With   the  object   of  diagnosing  the  lie,  presentation, 

and  position  of  the  fcetus. 

(3)  With  the  object  of  diagnosing  the  course  of  labour. 

(4)  With  the  object  of  diagnosing  the   presence  of  com- 

plications. 
The  Diagnosis  of  Pregnancy. — In  performing  abdominal  palpa- 
tion, the  position  of  the  patient  is  of  great  importance.  She 
must  be  so  placed  that  the  examiner  can  sit  at  her  right  side 
on  the  couch  and  place  his  hands  on  the  abdomen  without  any 
effort,  and  that  her  abdominal  muscles  are  relaxed  as  much  as 
possible.  With  these  objects  in  view,  she  lies  on  her  back, 
with  the  head  slightly  raised  and  supported  by  pillows,  her  arms 
extended  along  her  sides,  and  her  legs  extended  and  slightly 
separated.  Her  garments  and  the  bedclothes  are  so  arranged 
that  the  abdomen  is  visible.  The  examiner  then  sits  on  the 
couch  by  the  side  of  the  patient,  at  the  level  of  the  middle  of  the 
femora,  and  facing  her,  and  places  both  hands  flat  upon  the 
abdomen,  about  the  level  of  the  umbilicus,  care  being  first  taken 
to  ensure  that  the  bladder  is  empty,  and  that  the  examiner's  hands 
are  warm.  The  finger-ends  are  then  gently  sunk  into  the  abdomen 
with  a  view  to  determining  the  thickness  and  the  tension  of  the 
abdominal  wall,  and  the  presence  of  any  undue  tenderness  or 
pain  on  pressure.  As  soon  as  this  has  been  done,  the  finger-ends 
are  next  sunk  more  deeply  into  the  abdominal  wall,  with  the 
object  of  determining  the  existence  of  any  resistance  such  as 
would  be  caused  by  a  tumour  or  an  enlarged  uterus.  If  no 
resistance  is  experienced  at  the  level  of  the  umbilicus,  the  hands 
are  gently  drawn  downwards,  and  the  contents  of  the  false  pelvis 
carefully  ascertained.  If  there  is  still  no  resistance,  the  fingers 
are  sunk  as  deeply  as  possible  into  the  brim  of  the  true  pelvis. 
If,  on  the  other  hand,  the  fingers  meet  with  resistance  at  the  level 
of  the  umbilicus,  they  are  gently  pushed  upwards,  and  the  region 
between  the  umbilicus  and  the  ensiform  cartilage  carefully 
examined,  with  the  object  of  determining  the  upward  limit  of  the 
resistance.  Every  movement  must  be  made  with  gentleness  and 
deliberation.  Rough  or  sudden  movements  cause  pain,  and  a 
consequent  contraction  of  the  abdominal  muscles,  and  so  effectually 
defeat  their  own  object.  When  palpating  the  brim  of  the  true 
pelvis,  it  is  necessary  to  sink  the  tips  of  the  fingers  downwards  as 
deeply  as  possible.  In  order  to  do  this  it  is  well  to  tell  the 
patient  to  draw  deep  and  regular  inspirations,  while  at  the  same 
time  gentle  but  firm  pressure  is  made  with  the  fingers  of  both 
hands.  With  each  expiration  it  will  be  found  that  the  finger-tips 
gain  a  little  ground  and  penetrate  more  and  more  deeply  towards 


1 66  OBSTETRICAL  DIAGNOSIS 

the  brim,  until  finally  it  is  possible  to  reach  any  enlargement 
which  has  reached  the  level  of  the  brim  of  the  pelvis,  or,  in  the 
case  of  thin  patients,  even  one  which  lies  below  the  brim. 

As  soon  as  the  existence  of  such  a  resistance  as  would  be 
caused  by  a  pregnant  uterus  or  a  tumour  has  been  experienced, 
the  next  point  is  to  determine  its  nature.  It  may  be  caused  by  a 
pregnant  uterus,  a  myomatous  uterus,  or  an  ovarian  or  other 
abdominal  tumour.  A  pregnant  uterus  will  be  felt  as  a  smooth, 
more  or  less  globular,  mass,  medianly  situated,  and  of  a  some- 
what elastic  consistency.  If  we  keep  the  hands  applied  gently 
to  its  surface  for  a  few  moments,  we  shall  in  many  cases  be 
able  to  perceive  that  it  alternately  hardens  and  relaxes.  And, 
further,  if  pregnancy  is  sufficiently  advanced,  we  shall  be  able 
to  determine  the  existence  of  a  solid  body  floating  inside  it, 
and  to  appreciate  the  fact  that  this  solid  body  moves.  The  fact 
that  the  uterus  contains  a  movable  solid  body  inside  it  is  deter- 
mined by  a  movement  of  the  fingers,  known  as  external  ballotte- 
ment  (ballotter,  to  toss).  This  is  performed  by  suddenly  depressing 
the  abdominal  wall  over  a  prominent  part  of  the  uterus  with  the 
finger-tips,  and  then  keeping  the  fingers  in  position  for  a  moment. 
The  sudden  pressure  pushes  away  from  the  uterine  wall  the 
underlying  part  of  the  foetus,  which  then  floats  back  again  into 
its  former  position,  and  as  it  does  so  taps  gently  against  the 
fingers.  Another  method  of  obtaining  external  ballottement 
consists  in  laying  both  hands  over  the  uterus,  and  then  suddenly 
depressing  the  fingers  of  one.  The  foetus  is  displaced  by  the 
pressure,  and  pushed  over  to  the  opposite  side  of  the  uterus, 
where  it  taps  gently  against  the  fingers  of  the  other  hand.  In  the 
middle  months  of  pregnancy,  the  entire  foetus  can  be  moved  in  the 
uterus  in  this  manner.  In  the  later  months,  however,  it  is  only 
the  head  or  perhaps  a  limb  which  can  be  made  to  move,  as  the 
pressure  of  the  uterine  wall  controls  the  remainder  of  the  foetus. 

The  Diagnosis  of  the  Presentation  and  Position  of  the  Foetus. 
— The  method  of  performing  abdominal  palpation,  with  the  object 
of  diagnosing  the  lie,  presentation,  and  position  of  the  foetus, 
differs  somewhat  from  the  method  we  have  just  described.  The 
position  in  which  the  patient  is  placed  is,  however,  similar.  The 
examiner  sits  by  the  side  of  the  patient  at  the  level  of  the  pelvis, 
and  practises  successively  three  grips,  or  methods  of  applying  the 
hands.  If  further  information  is  required,  he  turns  in  the  opposite 
direction,  so  as  to  face  her  feet,  and  practises  a  fourth  grip. 

First  Grip. — The  first  grip,  or  the  fundal  grip,  is  made  as 
follows  : — Both  hands  are  placed  over  the  upper  part  of  the 
uterus,  slightly  to  each  side  of  the  middle  line,  in  such  a  position 
that  the  fingers  roof  over  the  fundus,  then  by  gentle  depression 
of  the  tips  and  by  slight  rotatory  movements,  the  outlines  of 
the  portion  of  the  foetus  which  lies  under  the  hands  are  deter- 
mined. In  almost  every  Case,  a  round,  resistant  mass  can  be  felt 
lying  either  in  the  middle  line,  or  somewhat  to  one  or  other  side 


ABDOMINAL  PALPATION 


167 


under  the  arch  of  the  ribs.  This  mass  consists  of  one  or  other  pole 
of  the  foetus.  To  distinguish  which  pole  it  is,  we  must  ascertain  its 
mobility,  its  shape,  its  size,  and  its  consistency.  The  head  is  more 
movable  than  the  breech,  for  two  reasons : — First,  on  account  of 
its  globular  shape,  it  is  not  so  completely  invested  by  the  uterus 
as  is  the  breech,  but  is  only  in  contact  with  the  uterine  walls  at 
certain  places.  Secondly,  the  articulations  of  the  neck  enable  it 
to  move  from  side  to  side  independently  of  the  trunk,  while  the 
breech,  being  portion  of  the  trunk,  can  only  move  en  bloc  with  the 
latter.     In  consequence  of  this,  it  is  possible  to  ballott  the  head 


Fig.  104. — Abdominal  Palpation  :  The  Fundal  Grip. 

between  the  hands — a  process  which  is  impossible  in  the  case  of 
the  breech.  In  shape,  the  head  is  rounder  and  more  uniform 
than  is  the  breech.  It  is  separated  from  the  trunk  by  a  groove 
or  depression  at  the  site  of  the  neck,  while  the  outline  of  the 
breech  is  continuous  with  that  of  the  trunk.  Further,  in  the  case 
of  the  podalic  pole,  the  feet  can  usually  be  recognised  lying  close 
to  the  breech,  and  in  many  cases  their  movements  can  be  felt. 
In  point  of  size,  the  podalic  pole  is  the  larger.  In  consistency, 
the  head  is  considerably  harder  ;  but  inasmuch  as  the  placenta 
often  lies  between  the  fundal  pole  of  the  foetus  and  the  examining 


1 68 


OBSTETRICAL  DIAGNOSIS 


fingers,  it  is  difficult  to  appreciate  this  point.  If  the  fundal 
tumour  is  displaced  to  one  or  other  side,  so  that  it  lies  under  the 
arch  of  the  ribs,  and,  consequently,  cannot  be  readily  palpated,  it 
will  be  extremely  difficult  to  ascertain  its  nature.  To  overcome 
this  difficulty,  press  the  lower  pole  of  the  foetus  towards  the  same 
side  as  that  at  which  the  upper  pole  lies.  This  will  have  the 
effect  of  displacing  the  upper  pole  forwards,  and  towards  the 
middle  line,  and  so  enabling  its  nature  to  be  determined. 

Second   Grip.— The    second,    or    umbilical,    grip   is    made    by 


Fig.  105.— Abdominal  Palpation  :  The  Umbilical  Grip. 


applying  both  hands  to  the  sides  of  the  uterus,  so  that  the  fingers 
lie  at  each  side  of  the  middle  line,  about  the  level  of  the  umbilicus. 
Then,  by  gently  depressing  and  rotating  the  fingers  as  before,  we 
can  in  the  large  majority  of  cases  determine  the  fact  that  there  is 
a  flat  resisting  mass  at  one  side,  while  at  the  other  there  is  either 
no  marked  resistance,  or  one  or  more  small  irregular  prominences 
can  be  felt.  If  there  is  any  difficulty  in  determining  the  existence 
of  greater  resistance  at  one  side  than  at  the  other,  the  hands 
placed  at  each  side  of  the  uterus  are  moved  synchronously  first 
towards  one  side  and  then  towards  the  other.     By  this  means, 


ABDOMINAL  PALPATION  169 

it  will  be  found  that  a  greater  resistance  is  offered  to  one  hand 
than  to  the  other.  If  this  area  of  resistance  is  followed  upwards 
and  downwards,  it  will  be  found  to  merge  itself  in  the  fundal  pole 
of  the  foetus  above,  and  in  the  pelvic  pole  of  the  foetus  below. 
This  resistance  is  caused  by  the  presence  of  the  back  of  the  foetus, 
while  the  irregular  prominences  at  the  opposite  side  are  formed 
by  parts  of  the  limbs.  More  rarely,  the  umbilical  grip  may 
determine  the  presence,  not  of  the  smooth  and  more  or  less  flat 


Fig.   106, — Abdominal  Palpation  :  The  First  Pelvic  Grip. 

outline  of  the  back,  but  of  a  rounded  mass  similar  to  the  mass 
hich  is  usually  found  at  the  fundus.     This  mass  is  formed  either 
by  the  foetal  head  or  breech. 

Third  Grip. — The  third,  or  Pawlic's,  grip  is  the  first  of  two  forms 
of  pelvic  grip.  It  is  made  with  the  fingers  of  one  hand  as  follows  : — 
Separate  the  fingers  of  the  right  hand  from  the  thumb  as  far  as 
possible.  Then,  sink  the  fingers  into  the  false  pelvis  immediately 
above  Poupart's  ligament  on  the  patient's  left  side,  and  the  thumb 


170 


OBSTETRICAL  DIAGNOSIS 


into  a  corresponding  point  on  the  right  side.  If  the  fingers  and 
thumb  are  then  approximated,  they  will  find  between  them  a 
solid  body.  If  the  patient  is  not  in  labour,  this  solid  body  can 
only  be  one  or  other  of  the  fcetal  poles — i.e.,  either  the  head  or  the 
breech.  The  diagnosis  between  them  is  not  difficult,  and  is  made 
as  in  the  case  of  the  fundal  pole.  The  head  is  firmer  and  rounder 
than  the  breech.  There  is  a  groove  between  it  and  the  body — 
the  groove  of  the  neck — which  usually  runs  obliquely  upwards, 
and  is  lowest  on  the  side  of  the  fcetal  back;  and,  if  the  head  is  not 


Fig.   107. — Abdominal  Palpation  :  The  Second  Pelvic  Grip. 


fixed,  it  is  more  movable  than  the  breech  on  account  of  the 
cervical  articulations.  Further,  in  the  case  of  the  breech,  the 
feet  may  be  felt  to  one  or  other  side.  If  the  patient  is  in  labour, 
and  the  head  has  passed  the  brim,  the  resistance  experienced  by 
the  fingers  may  also  be  due  to  some  portion  of  the  fcetal  trunk 
which  has  become,  or  is  becoming,  impacted  in  the  pelvis.  In 
such  a  case,  the  part  of  the  foetus  which  is  most  usually  felt 
is  formed  by  the  shoulder  and  a  part  of  the  back.  If  there  is  a 
cephalic  presentation,  and  if  the  patient  is  in  labour,  there  may  be 
either  a  vertex,  a  face,  or  a  brow  presentation.     In  the  case  of  a 


ABDOMINAL  PALPATION  171 

vertex  presentation,  as  has  been  mentioned,  the  groove  of  the 
neck  runs  obliquely  upwards,  being  lowest  on  the  side  of  the  back, 
inasmuch  as  the  chin  lies  higher  than  the  occiput.  Also,  the  head 
lies  higher  above  the  brim  on  the  side  of  the  face — i.e.,  on  the 
opposite  side  to  that  at  which  the  back  is  felt — than  it  does  on 
the  side  of  the  occiput.  In  the  case  of  a  brow  presentation,  the 
groove  of  the  neck  is  almost  horizontal,  as  the  occiput  and  chin  lie 
almost  on  the  same  level.  In  the  case  of  a  face  presentation,  the 
groove  of  the  neck  again  runs  obliquely,  but  it  is  higher  on  the  side 
of  the  back,  as  the  chin  here  lies  lower  than  the  occiput.  If  the 
head  is  fixed  in  the  pelvic  brim  and  labour  has  not  commenced, 
we  know  that  the  vertex  must  be  presenting  (Pinard). 

Fourth  Grip. — In  making  the  fourth,  or  second  pelvic,  grip,  the 
examiner  turns  round  so  as  to  face  the  feet  of  the  patient.  He 
then  places  the  finger-tips  of  both  hands  above  Poupart's  ligament, 
one  on  each  side,  and  endeavours  to  sink  them  down  as  far  as 
possible  into  the  pelvic  brim.  Whilst  doing  this,  he  may  experience 
one  of  two  sensations.  He  may  find  that  his  fingers  are  arrested 
by  a  fifm,  resistant  mass,  or  he  may  find  that  they  sink  without 
difficulty  into  the  pelvic  cavity,  experiencing  no  more  resistance 
than  is  caused  by  the  abdominal  walls  and  subjacent  soft  parts. 
In  the  first  case,  the  presenting  part  has  entered  or  has  passed  the 
brim  of  the  pelvis,  and  is  fixed  there ;  in  the  second  case,  the 
presenting  part  is  not  fixed.  If  the  head  has  sunk  deeply  into 
the  pelvis,  the  diagnosis  of  the  actual  presentation  is  made  by 
noting  the  difference  in  its  level  at  each  side.  If  the  pelvic  brim 
is  discovered  to  be  empty,  the  fingers  are  drawn  slightly  upwards 
and  the  false  pelvis  carefully  palpated.  When  the  lie  is  longitu- 
dinal— i.e.,  in  the  majority  of  cases,  one  or  other  pole  of  the 
foetus  will  be  found  freely  movable  just  above  the  brim.  When 
the  lie  is  transverse  or  oblique,  a  foetal  pole  will  be  found  lying  in 
one  or  other  iliac  region,  or  even  higher  at  one  or  other  side  of 
the  umbilicus. 

Accordingly,  by  means  of  these  four  grips,  it  is  possible  to 
ascertain  the  lie,  presentation,  and  position  of  the  foetus.  Whether 
the  lie  is  longitudinal  or  transverse  is  determined  by  noting  the 
fact  that  the  back  lies  more  or  less  vertically,  or  more  or  less 
transversely  ;  while  cephalic  presentations  are  distinguished  from 
podalic  presentations  by  noting  the  characteristics  of  the  fundal 
and  pelvic  pole  of  the  foetus.  The  various  presentations  of  the 
head  are  mainly  determined  by  noting  the  relative  heights  of  the 
chin  and  the  occiput.  It  is  more  difficult  to  determine  the  exact 
nature  of  the  presentation  in  podalic  lies.  If  the  feet  are  felt 
near  the  pelvic  brim,  we  know  we  are  dealing  with  a  complete 
pelvic  presentation  ;  but  inasmuch  as  this  may  change  during 
labour,  owing  to  the  feet  becoming  caught  at  the  brim,  the 
knowledge  is  not  of  any  great  practical  importance.  The  position 
of  the  foetus  is  determined  by  the  umbilical  grip,  by  means  of 
which  we  ascertain  in  longitudinal  lies  at  which  side  the  back 


172  OBSTETRICAL  DIAGNOSIS 

is  situated,  and  in  transverse  lies  at  which  side  the  head  is 
situated. 

The  Diagnosis  of  the  Course  of  Labour. — In  making  a  diagnosis 
of  the  course  of  labour,  the  same  method  of  palpation  is  adopted 
as  in  diagnosing  presentations  and  positions.  The  course  of 
labour  can  be  followed,  first,  by  noting  the  descent  of  the 
presenting  part,  and,  secondly,  by  noting  the  changes  in  the  form 
of  the  uterus.  The  descent  of  the  presenting  part  is  followed  by 
the  pelvic  grips.  By  the  first  pelvic  grip,  we  can  ascertain  the 
fixation  of  the  presenting  part,  and  can  follow  its  descent  until 
the  chin  has  passed  the  brim.  By  the  second  pelvic  grip,  we  can 
follow  its  descent  after  this  has  occurred.  The  advantages  of  this 
method  of  following  the  course  of  labour  over  the  more  usual 
method  of  repeated  vaginal  examinations  will  be  subsequently 
discussed. 

The  changes,  which  take  place  in  the  form  of  the  uterus,  will  be 
more  readily  understood  after  the  mechanism  of  labour  has  been 
discussed.  Here,  it  is  sufficient  to  state  that,  after  the  membranes 
have  ruptured  and  the  liquor  amnii  has  in  great  part  escaped,  the 
ovoid  form  of  the  uterus  is  to  some  extent  lost,  as  the  latter 
contracts  down  more  tightly  on  the  foetus.  Also,  and  in  con- 
sequence of  this,  the  mobdity  of  the  foetus  inside  the  uterus 
is  diminished. 

The  Presence  of  Complications.  —  In  order  to  determine  the 
presence  of  complications,  the  following  information  must  be 
ascertained  : — The  relation  of  the  presenting  part  to  the  pelvic 
brim ;  the  distinctness  with  which  the  foetal  parts  can  be  felt ;  and 
the  effect  of  the  uterine  contractions  on  the  uterine  muscle. 

(i)  The  Relation  of  the  Presenting  Part  to  the  Pelvic  Brim. — As  we 
shall  presently  learn,  the  relation  of  the  presenting  part  to  the 
pelvic  brim  depends  upon  the  period  of  pregnancy,  and  on  whether 
the  patient  is  a  primipara  or  a  multipara.  In  normal  cases,  the 
rule  is  that  the  presenting  vertex  is  fixed  in  the  pelvic  brim  during 
the  last  three  or  four  weeks  of  pregnancy  in  the  case  of  a  primipara, 
whilst  in  the  case  of  a  multipara  it  is  not  fixed  until  she  actually 
comes  into  labour.  In  abnormal  cases,  on  the  other  hand,  in 
which  either  the  normal  relations  between  the  size  of  the  pre- 
senting part  and  the  size  of  the  pelvic  brim  are  altered,  or  in 
which  there  is  some  obstacle  to  the  descent  of  the  presenting  part, 
the  latter  is  not  found  fixed  in  the  brim  at  the  usual  time.  The 
fixity  or  non-fixity  of  the  presenting  head  at  a  time  at  which  it 
ought  to  be  fixed  is  a  point  on  the  importance  of  which  too  much 
insistence  cannot  be  laid.  It  is  perhaps  the  most  important  point 
which  is  brought  out  by  abdominal  palpation,  inasmuch  as  if  the 
head  is  fixed  at  the  proper  time  almost  every  abnormality  which 
may  affect  the  first  two  stages  of  labour  is  eliminated  ;  while,  on 
the  other  hand,  if  the  head  is  not  fixed,  we  know  that  something 
is  wrong,  the  nature  of  which  must  be  determined  as  soon  as 
possible.     The  non-fixity  of  the  presenting  part  may  be  due  to  the 


VAGINAL  EXAMINATION  173 

presence  of  the  following  pathological  conditions  : — Malpresenta- 
tions  of  the  head  ;  multiple  pregnancy  ;  contracted  pelvis  ;  lateral 
or  anterior  displacements  of  the  uterus  ;  hydrocephalic  head  ; 
placenta  previa  ;  hydramnios  (excessive  amount  of  liquor  amnii) ; 
tumours  of  the  uterus,  of  the  genital  organs,  or  of  the  pelvis,  lying 
in  or  near  the  brim  ;  foetal  malformations. 

The  diagnosis  of  the  exact  cause  of  the  non-fixation  will  be 
made  by  further  examination,  the  details  of  which  will  be 
subsequently  described. 

.  (2)  The  Distinctness  with  which  the  Foetal  Parts  can  be  felt. — In 
normal  cases,  there  should  be  no  great  difficulty  in  palpating  the 
fcetal  parts,  unless  the  patient  is  stout,  or  the  abdominal  muscles 
are  rigidly  contracted.  In  the  absence  of  either  of  these  causes, 
difficulty  is  indicative  of  the  presence  of  some  abnormal  condition. 
Such  conditions  are  : — Hydramnios  ;  tumours  of  the  uterus  ; 
tumours  of  the  ovaries ;  ascites  ;  intra-uterine  haemorrhage  ;  an 
abnormally  situated  placenta ;  tonic  contraction  of  the  uterus  ; 
hydatidiform  mole  ;  a  macerated  fcetus. 

(3)  The  Effect  of  the  Uterine  Contractions  on  the  Uterine  Muscle. — 
As  will  be  seen  when  the  phenomena  of  labour  are  discussed, 
certain  definite  changes  occur  in  the  uterine  muscle  as  labour 
proceeds,  and  become  more  marked  the  longer  labour  lasts. 
When  labour  is  prolonged  to  a  pathological  extent,  these  changes 
make  themselves  obvious  by  their  effect  on  the  uterine  con- 
tractions, on  the  situation  of  the  retraction  ring,  and  on  the  round 
ligaments,  all  of  which  can  be  ascertained  by  abdominal  palpation. 
The  character  of  the  uterine  contractions  is  determined  by  laying 
the  hand  gently  on  the  uterus,  and  noting  the  force  and  the 
duration  of  the  contraction,  and  the  length  of  the  interval  between 
succeeding  contractions.  The  situation  of  the  retraction  ring,  or 
junction  between  the  upper  and  lower  uterine  segments,  is  found 
by  palpating  the  uterus  from  the  level  of  the  umbilicus  down- 
wards, when  in  certain  cases  the  ring  will  be  felt  as  an  oblique 
depression  of  the  uterine  wall.  A  round  ligament  can  be  felt  by 
gently  drawing  the  fingers  across  the  sides  of  the  uterus  from 
the  region  of  the  anterior  superior  spine  of  the  ilium  towards 
the  umbilicus.  The  ligament  will  then  be  felt  as  a  thickened 
cord,  which  slips  under  the  fingers.  As  a  rule,  owing  to  the 
dextro-torsion  of  the  uterus,  only  the  left  round  ligament  can  be 
reached. 

VAGINAL  EXAMINATION 

The  examination  of  the  vagina  is  the  oldest  method  of  diagnosing 
the  existence  of  pregnancy  and  the  course  of  labour,  and  in  spite 
of  the  not  inconsiderable  danger  by  which  it  is  accompanied, 
it  is  still  the  most  favourite  method.  The  relative  advantages  of 
palpation  and  of  vaginal  examination  will  be  subsequently 
discussed. 


174 


OBSTETRICAL  DIAGNOSIS 


Under  the  heading  '  Vaginal  Examination  '  is  also  included 
combined  abdominovaginal  examination  or  bi-manual  examina- 
tion, as  this  method  is  often  used  instead  of  simple  vaginal 
examination,  particularly  in  the  early  months  of  pregnancy. 

A  simple  vaginal  examination  is  made  as  follows  : — The  patient 
is  placed  on  her  left  side,  her  hips  projecting  slightly  beyond  the 
side  of  the  couch,  and  her  knees  a  little  flexed,  the  external 
genitals  having  been  cleansed  and  disinfected  as  has  been  already 
described.  The  examiner,  having  then  washed  and  disinfected 
his  hands,  separates  the  labia  with  the  fingers  of  the  left  hand, 
and  gently  passes  the  fore-finger,  or  the  fore  and  middle  fingers, 
of  the  right  hand  into  the  vagina,  if  possible  without  touching  the 
external  genitals.  The  finger  is  then  passed  upwards  towards 
the  upper  limit  of  the  vagina,  and  the  cervix,  the  vault  of  the 
vagina,  the  vaginal  mucous  membrane,   and  the  vulvar  orifice 


Fig.   108. — The  Hand  and  the  Foot  of  the  New-born  Infant. 


carefully  in  turn  examined.  During  pregnancy,  we  examine  the 
cervix  with  the  object  of  determining  its  consistence  and  shape,  and 
the  presence  of  any  pathological  conditions,  such  as  lacerations  or 
tumours.  During  labour,  we  examine  it  with  the  object  of  ascer- 
taining the  extent  to  which  it  has  been  taken  up  into  the  body  of 
the  uterus,  the  degree  to  which  it  is  dilated,  and  the  nature  of  the 
presenting  part  which  is  felt  through  it.  The  presenting  part  is 
examined  with  a  view  to  determine  its  nature,  and  to  ascertain 
whether  it  is  fixed  in  the  pelvic  brim  or  not.  The  nature  of  the 
presenting  part  is  determined  by  noting  its  shape  and  contour, 
and  its  surface  markings.  A  vertex  presentation,  or  an  anterior  or 
posterior  fontanelle  presentation,  presents  a  smooth  and  rounded 
surface,  intersected  by  various  surface  markings.  A  distinction  is 
made  between  them  by  noting  the  shape  of  these  surface  mark- 
ings— i.e.,  of  the  sutures  and  fontanelles,  and  their  position  relative 
to  one  another  and  to  the  pelvic  cavity.     A  face  presentation  is 


VAGINAL  EXAMINATION 


175 


felt  as  a  more  or  less  irregular  and  hard  surface,  according  to  the 
degree  to  which  its  outlines  are  obscured  by  the  presence  of  a 
caput  succedaneum.  Its  characteristic  markings  are  furnished 
by  the  outlines  of  the  facial  bones  and  by  the  aperture  of  the 
mouth.  A  brow  presentation  is  distinguished  by  the  fact  that 
one  side  of  the  presenting  part  is  smooth  and  rounded,  with  the 
characteristics  of  the  cranium,  the  other  side  irregular,  with  the 
characteristics  of  the  face.  A  pelvic  presentation  is  felt  as  a 
smooth,  rounded  surface,  softer  than  the  head,  but  offering  three 
points  of  bony  resistance,  formed  by  the  tuberosities  of  the 
ischium  and  the  tip  of  the  coccyx.  Its  surface  markings  are  the 
aperture  of  the  anus,  the  external  genitals,  and,  if  the  finger  is 


Fig.  109. — Diagram  representing  the  Normal  Ball-valve  Action  of 
the  Head,  and  the  consequent  Slight  Protrusion  of  the  Mem- 
branes into  the  Vagina. 


passed  upwards,  the  cleft  between  the  thighs,  or  between  each 
thigh  and  the  abdominal  wall.  If  the  pelvic  presentation  is  com- 
plete, the  feet  will,  in  some  cases,  be  felt  at  one  or  other  side.  A 
shoulder  presentation,  when  driven  into  the  brim,  presents  a 
smooth  and  somewhat  rounded  surface,  which  is  softer  than  the 
cranium,  and  which  possesses  certain  bony  landmarks,  formed  by 
the  shoulder-joint  and  the  ribs.  This  presentation,  as  well  as 
some  of  the  others,  may  be  complicated  by  the  presence  of  a  limb. 
In  such  cases,  the  examining  finger  may  reach  an  elbow  or  a 
hand,  a  knee  or  a  foot.  These  parts  are  recognised  by  their 
shape  and  range  of  movement  (v.  Fig.  108).  A  hand  is  relatively 
smaller  than  a  foot,  the  outline  of  the  tops  of  the  fingers  is  curved, 
the  thumb  can  be  opposed  and  apposed  to  the  palm.     On  the 


176  OBSTETRICAL  DIAGNOSIS 

other  hand,  the  outline  of  the  tops  of  the  toes  is  straight,  the 
articulations  of  the  great-toe  do  not  permit  of  any  lateral  move- 
ment, while  the  shape  of  the  os  calcis  is  characteristic.  The 
elbow  is  relatively  smaller  than  the  knee,  and  lacks  the  patellar 
ligament  and  the  tuberosity  of  the  tibia.  To  determine  whether 
the  presenting  part  is  fixed  or  not,  endeavour  to  gently  push  it 
upwards.     If  this  is  possible,  it  is  obviously  not  fixed. 

The  condition  of  the  membranes  is  next  ascertained,  with  the 
view  of  determining  whether  they  are  intact  or  not,  and,  in  the 
former  case,  the  manner  in  which  they  protrude  into  the  vagina 
during  a  contraction  of  the  uterus  is  also  noted.  As  has  been 
already  mentioned,  abdominal  palpation  furnishes  us  with  a  simple 


Fig.  iio. — Diagram  representing  the  Failure  of  the  Ball-valve 
Action  of  the  Head,  and  the  consequent  Commencing  Undue 
Protrusion  of  the  Membranes  into  the  Vagina. 


means  of  telling  in  a  reliable  manner  whether  labour  is  likely  to  be 
uncomplicated  or  the  reverse.  If  we  find  that  the  head  is  fixed 
in  the  pelvic  brim  at  a  time  at  which  it  ought  normally  to  be  fixed, 
we  know  that  most  complications  which  can  offer  an  obstacle  to 
the  descent  of  the  foetus  are  absent.  Similarly,  vaginal  examina- 
tion affords  a  valuable  criterion  by  which  we  can  determine  the 
presence  or  absence  of  such  complications.  This  consists  of  the 
extent  to  which  the  membranes  protrude  into  the  vagina  during 
a  contraction  of  the  uterus.  Under  normal  circumstances,  the 
liquor  amnii  is  divided  into  two  portions — a  larger  portion  which 
surrounds  the  body  of  the  foetus,  and  a  smaller  portion  which  lies 
in  front  of  the  head.  Prior  to  the  fixity  of  the  head  and  the  onset 
of  labour,  these  two  portions  communicate  with  one  another,  but, 


VAGINAL  EXAMINATION 


177 


as  soon  as  active  contractions  of  the  uterus  commence,  this  com- 
munication is  interrupted  by  what  is  known  as  the  ball-valve 
action  of  the  presenting  head.  This  action  is  very  simple  and 
effective.  When  a  contraction  of  the  uterus  occurs,  the  head  is 
driven  down  and  plugs  the  lower  segment  of  the  uterus  so  com- 
pletely that,  in  spite  of  the  increased  intra-uterine  pressure,  no 
liquor  amnii  is  driven  downwards  below  the  head.  The  stronger 
is  the  driving  force,  the  more  tightly  does  the  head  plug  the  canal 
in  which  it  is  lying.  The  extent  to  which  the  membranes  pro- 
trude through  the  cervix  depends  upon  the  amount  of  liquor 
amnii  which  lies  in  front  of  the  head,  and,  as  we  now  see,  this 
amount  depends  on  the  effectiveness  or  failure  of  the  ball-valve 
action  of  the  head.     Normally,  the  amount  of  fluid  in  front  of 


Fig.  hi.  —  Diagram  representing  the  Failure  of  the  Ball-valve 
Action  of  the  Head,  and  the  consequent  Marked  Protrusion 
of  the  Membranes  into  the  Vagina. 

the  head  is  small,  and  if  the  ball- valve  action  is  perfect  is  not 
increased  during  a  contraction  (v.  Fig.  109).  If,  on  the  other 
hand,  there  is  a  failure  in  this  action,  with  each  contraction  addi- 
tional liquor  amnii  is  driven  down  and  the  membranes  protrude 
into  the  vagina  in  the  form  of  a  long  finger-shaped  or  pear-shaped 
cyst,  which  may  completely  fill  the  vagina  or  may  even  bulge 
outwards  externally  (v.  Figs.  110,  in).  Failure  in  the  ball- 
valve  is  caused  by  any  condition  which  affects  the  shape  of  the 
presenting  part,  or  of  the  canal  into  which  it  should  fit,  or 
which  prevents  the  head  from  descending  into  its  proper  position 
in  the  canal.  Consequently,  by  determining  the  manner  in  which 
the  membranes  protrude  into  the  vagina  during  a  contraction, 
we  are  enabled  to  ascertain  the  presence  or  absence  of  any  con- 

12 


178  OBSTETRICAL  DIAGNOSIS 

dition  which  offers  an  obstruction  to  the  descent  of  the  presenting 
part. 

If  the  membranes  are  ruptured,  the  caput  succedaneum  will  be 
felt,  and  can  usually  be  distinguished  without  difficulty.  A  large 
caput  succedaneum  may  possibly  be  mistaken  for  unruptured 
membranes — a  mistake  which  may  lead  to  serious  consequences 
if  attempts  are  made  to  rupture  it.  A  diagnosis  can  usually  be 
made  by  examining  the  swelling  during  a  contraction  of  the 
uterus,  as  the  bag  of  membranes  will  then  immediately  become 
tense  and  as  rapidly  relax  again  as  the  contraction  passes  off, 
while  a  caput  succedaneum  will  not  alter.  Further,  a  caput 
succedaneum  will  pit  under  the  pressure  of  the  examining  finger, 
while  in  the  case  of  the  bag  of  membranes  the  finger  will 
momentarily  displace  fluid,  which  will  at  once  return  when  the 
pressure  is  relaxed.  Occasionally,  however,  there  is  no  fluid  in 
front  of  the  head,  and  in  such  cases,  where  flaccid  membranes  lie 
close  to  a  large  caput  succedaneum,  the  difficulty  of  ascertaining 
the  presence  of  these  membranes  is  considerable.  A  caput 
succedaneum  may  also  be  mistaken  for,  or  confounded  with,  an 
encephalocele.  In  the  case  of  the  latter,  however,  the  skin  cover- 
ing it  is  not  cedematous,  and  the  contents  can,  as  a  rule,  be  pushed 
back  into  the  cranial  cavity. 

The  last  point  to  be  determined  in  the  region  of  the  cervix  is 
the  presence  of  any  complication  such  as  prolapse  or  presentation 
of  the  cord  or  abnormally  low  situation  of  the  placenta.  The 
characteristics  of  the  cord  are  so  obvious  that  it  cannot  be  mis- 
taken. A  placenta  which  is  situated  within  reach  of  the  examining 
finger  can  also  be  readily  recognised.  It  may  be  simulated  by  a 
firm  clot  lying  inside  the  cervix,  but  a  clot  can  be  readily  broken 
down  by  slight  pressure  of  the  finger,  while  the  placenta  is  more 
resisting  as  it  is  firmer  in  consistency. 

The  vaginal  vault  is  next  examined  with  the  object  of  deter- 
mining the  presence  of  any  tumours  situated  in  the  pelvic  cavity, 
and  springing  from  either  the  uterus  or  the  pelvic  bones.  At  the 
same  time,  the  contour  of  the  pelvic  brim  should,  if  possible,  be  also 
examined  to  ascertain  the  presence  of  any  small  projections  or  of 
marked  contraction.  If  there  is  any  reason  to  suspect  the  presence 
of  tumours  or  deformities  of  the  pelvis,  the  patient  should  be 
placed  under  an  anaesthetic,  the  hand  introduced  into  the  vagina, 
and  the  internal  surfaces  of  the  pelvis  thoroughly  examined. 

The  vaginal  mucous  membrane  is  next  examined  in  order  to 
determine  its  character,  the  presence  or  absence  of  cicatrices, 
ulcers,  or  fistulas,  and  the  nature  and  amount  of  the  fluid  with 
which  it  is  bathed.  The  finger  is  also  swept  round  the  pelvic 
cavity  with  a  view  to  ascertaining  its  size  and  the  presence  of  any 
bony  outgrowths  or  marked  contraction  of  the  outlet. 

Finally,  the  vulva  and  perinaeum  are  examined,  with  the  object 
of  ascertaining  the  size  and  dilatability  of  the  vulvar  orifice,  the 
presence  of  old  lacerations,  or  of  any  other  pathological  condition. 


VAGINAL  EXAMINATION  179 

A  combined  abdominovaginal,  or  bi-manual,  examination  is 
made  as  follows  : — The  patient  lies  on  her  back  on  a  couch 
or  bed,  or,  by  preference,  on  a  gynaecological  chair,  her  legs 
flexed  and  abducted.  If  the  patient  is  on  a  couch,  the  examiner 
stands  or  kneels  by  her  side,  and,  separating  the  labia  with  the 
fingers  of  the  left  hand,  passes  the  right  fore-finger,  or  fore 
and  middle  fingers,  into  the  vagina.  The  fingers  are  passed 
upwards  until  they  lie  beneath  the  cervix,  and  then  the  fingers  of 
the  opposite  hand  are  placed  on  the  abdominal  wall ;  the  tips  are 
sunk  into  the  abdomen  in  the  region  of  the  middle  line,  slightly 
below  or  about  the  level  of  the  umbilicus,  and  an  attempt  is  made 
to  ascertain  what  lies  between  the  fingers.  The  abdominal  fingers 
are  gently  rotated  over  the  region  of  the  false  pelvis,  with  the 
object  of  ascertaining  the  outlines  and  size  of  any  tumour  which 
may  be  formed  by,  or  be  in  the  region  of,  the  uterus.  If  no 
resistance  is  felt  between  the  fingers,  the  vaginal  fingers  are 
passed  into  the  posterior  fornix,  and  the  abdominal  fingers  are 
sunk  more  deeply  into  the  pelvis.  In  this  manner,  the  presence 
of  any  tumour  in  Douglas's  pouch  is  determined.  As  soon  as  this 
has  been  done,  the  fingers  are  drawn  to  one  or  other  side  of  the 
middle  line,  and  the  vaginal  fingers  are  moved  into  the  correspond- 
ing vaginal  lateral  fornix.  Then,  both  hands  are  drawn  gently 
downwards  towards  the  anterior  wall  of  the  pelvis  and  parallel 
with  the  plane  of  the  pelvic  brim.  In  this  manner,  the  presence 
of  any  tumour  situated  to  one  or  other  side  of  the  middle  line  is 
ascertained.  If  the  patient  is  on  a  gynaecological  couch,  a  more 
careful  examination  can  be  made.  In  such  a  case,  the  examiner 
stands  in  front  of  the  couch,  and,  placing  his  right  foot  on  a  stool, 
passes  the  fingers  of  his  right  hand  into  the  vagina.  He  then 
rests  the  right  elbow  on  the  right  knee,  in  order  to  allow  the  vaginal 
fingers  to  be  free  from  the  cramping  weight  of  the  arm.  The 
remainder  of  the  examination  is  made  as  has  been  described,  save 
that  it  is  generally  considered  advisable  to  examine  the  left  side 
of  the  pelvis  with  the  right  fingers  in  the  vagina  and  the  left  hand 
on  the  abdominal  wall,  and  the  right  side  of  the  pelvis  with  the 
hands  reversed — i.e.,  with  the  left  fingers  in  the  vagina.  In  order 
to  make  a  satisfactory  examination  three  points  must  be  attended 
to  : — The  bladder  must  be  empty ;  all  unnecessary  movements  of 
the  vaginal  fingers  must  be  avoided ;  and  all  movements  of  the 
fingers  must  be  made  as  gently  as  possible. 

By  means  of  a  combined  abdomino- vaginal  examination,  we 
can  determine  the  shape,  size,  and  consistency  of  the  uterus  in 
the  early  months  of  pregnancy,  the  presence  or  absence  of  any 
tumour  in  the  pelvis,  the  presence  of  any  alteration  in  the  con- 
sistency of  the  lower  uterine  segment,  and  the  presence  of  any 
movable  body  inside  the  uterus.  The  method  of  determining  the 
consistency  of  the  lower  uterine  segment  and  the  presence  of 
any  movable  body  inside  the  uterus  requires  a  more  detailed 
description. 

12 — 2 


i8o 


OBSTETRICAL  DIAGNOSIS 


As  will  be  subsequently  learnt,  an  important  phenomenon  of 
pregnancy  is  the  softening  of  the  lower  uterine  segment.  The 
effect  of  this  softening  is  to  convey  the  impression  to  the  examin- 


Fig.  112. — Hegar's  Sign  of  Pregnancy. 

Diagram  showing  the  effect  of  the  softening  of  the  lower  segment  of  uterus. 
The  outline  shows  the  actual  shape  of  .the  uterus  ;  the  shaded  portion  its 
apparent  shape  as  felt  by  bi-manual  examination. 

ing  fingers  that  the  body  of  the  uterus  is  globular  in  outline  and 
firm  in  consistency,  that  the  cervix  is  also  firm  in  consistency,  and 
that  the  intermediate  part  of  the  uterus — i.e.,  the  lower  part  of  the 
body  and  the  upper  part  of  the  cervix — is  non-existent  (v.  Fig.  1 1 2). 


Fig  113. — Hegar's  Sign  of  Pregnancy. 
The  method  of  obtaining  the  sign  by  bi-manual  examination. 

This  apparent  obliteration  of  the  lower  uterine  segment  is  known 
as  Hegar's  sign  of  pregnancy,  and  is  due  to  the  extreme  softening 
which  the  uterine  tissue  undergoes  in  this   region.     It  will  be 


VAGINA  L  EX  A  MINA  TION 


181 


again  referred  to  in  its  proper  place.  Its  presence  can  be  ascer- 
tained in  two  ways.  Press  the  body  of  the  uterus  gently  down- 
wards into  the  pelvis  with  the  hand  on  the  abdominal  wall,  and 
with  the  vaginal  fingers  grasp  the  junction  of  the  body  and 
cervix  between  the  index  finger  in  the  posterior  fornix  and  the 
thumb  in   the  anterior  fornix.     If  the  softening  of  pregnancy  is 


Fig.   114. — Internal  Ballottement. 

Diagram  showing  the  manner  in  which    internal   ballottement  is  obtained, 
the  fingers  in  the  vagina  pushing  the  presenting  part  upwards. 

present,  the  yielding  nature  of  the  cervix  will  be  so  marked  that 
the  finger  and  thumb  can  be  almost  brought  into  contact  with 
one  another,  while  above  will  be  felt  the  relatively  firm  body, 
and  below  the  relatively  firm  cervix.  The  alternative  method 
consists  in  sinking  the  fingers  of  the  abdominal  hand  into  the 


1 82  OBSTETRICAL  DIAGNOSIS 

pelvis  immediately  above  the  symphysis,  taking  care  that  they 
are  below  the  body  of  the  uterus.  Then  pass  the  vaginal  fingers 
into  the  posterior  fornix  and  endeavour  to  approximate  them  to 
the  fingers  of  the  other  hand.  In  this  way,  the  entire  lower 
uterine  segment  will  be  included  between  the  fingers,  and  it  will 
be  possible  to  estimate  its  consistency  (v.  Fig.  113). 

The  presence  of  a  movable  body  inside  the  uterus  can  be  ascer- 
tained by  the  performance  of  internal  ballottement,  a  procedure 
which  is  identical  in  its  object  with  the  performance  of  external 
ballottement.  The  vaginal  fingers  are  placed  under  the  body  of 
the  uterus,  in  the  anterior  fornix  if  the  uterus  is  in  its  normal 
position,  in  the  posterior  fornix  if  it  is  retroverted.  Then,  push 
the  fingers  suddenly  upwards  against  the  most  dependent  part  of 
the  body  of  the  uterus  in  such  a  manner  as  to  slightly  depress  its 
wall,  and  keep  them  in  this  position  for  a  moment.  If  the  uterus 
(v.  Fig.  114)  contains  a  foetus  of  sufficient  size  to  be  felt  and 
sufficiently  mobile  to  be  displaced  in  the  liquor  amnii  by  the 
upward  push,  a  gentle  tap — the  choc  en  retour — will  be  felt  by  the 
fingers  as  the  foetus  again  floats  down  into  its  former  position. 


AUSCULTATION 

Auscultation  of  the  uterus  as  a  means  of  diagnosis  is  entirely 
a  product  of  the  nineteenth  century.  In  181 8,  Mayor  of  Geneva 
announced  that  the  pulsations  of  the  foetal  heart  could  be  heard 
in  advanced  pregnancy  by  the  ear  applied  to  the  abdomen  of  the 
mother.*  His  discovery  did  not  apparently  at  the  time  attract 
any  great  attention,  and  it  was  not  until  a  few  years  later  that 
the  possibility  of  auscultating  the  heart  became  generally  known 
through  a  communication  to  the  French  Academy  by  Lejumeau 
de  Kergaradecf  The  latter,  whilst  endeavouring  to  determine 
whether  it  was  possible  to  hear  the  wave  sound  produced  in 
liquor  amnii  by  the  motions  of  the  foetus,  heard  instead  a  sound 
which  he  compared  to  the  ticking  of  a  watch.  He  noted  that 
these  sounds  were  repeated  from  143  to  148  times  in  the  minute, 
while  the  pulse-rate  of  the  mother  was  only  70.  The  importance 
of  this  method  of  deciding  the  presence  and  life  of  the  foetus  was 
apparent  to  both  observers.  Lejumeau  de  Kergaradec  followed 
his  discovery  by  another  of  equal  interest,  though  of  not  so  great 
practical  importance,  namely,  the  detection  of  the  existence  of 
a  blowing  sound  or  souffle  synchronous  with  the  pulse-rate  of 
the  mother.  Evory  Kennedy — a  former  master  of  the  Rotunda 
Hospital — advanced  the  knowledge  of  obstetrical  auscultation 
a  step  further  by  describing  a  pulsation  and  a  souffle  heard  in 
advanced  pregnancy,  and  having  their  origin  in  the  vessels  of  the 

*   '  Bibliotheque  Universelle  de  Geneve,'  torn.  ix. ,  November,  1818. 
■j-  '  Memoire  sur  l'Auscultation  applique  a  l'litude  de  la  Grossesse,'  Paris, 
1822. 


AUSCULTATION  183 

umbilical  cord,  and  so  called  by  him  the  funic  souffle.  These 
sounds  were  synchronous  with  the  foetal  heart."  In  1838, 
Naegele  drew  attention  to  the  fact  that  '  the  sound  produced  by 
the  plunging  movements  of  the  child's  limbs  can  be  heard  much 
earlier  than  they  can  be  felt  by  the  practitioner,  or  even  by  the 
patient  herself.'!  Finally,  in  1847,  Depaul  described  the  practice 
of  auscultation  as  a  means  of  diagnosing  the  presentation  and 
position  of  the  foetus. :[; 

From  the  time  of  Depaul  on,  the  practice  of  auscultation  as  a 
means  of  diagnosing  the  existence,  the  life,  the  presentation  and 
position  of  the  foetus,  and  even  the  probable  situation  of  the 
placenta,  has  steadily  increased  in  popularity.  At  the  present 
day,  when  the  importance  of  supplanting  internal  by  external 
manipulations  is  appreciated,  the  importance  of  auscultation  is 
fully  recognised,  both  as  a  mode  of  diagnosis  for  which  there  is 
no  substitute,  and  as  an  auxiliary  to  abdominal  palpation. 

Auscultation  can  be  carried  out  either  through  the  intermediary 
of  a  stethoscope,  or  directly  by  placing  the  ear  on  the  abdomen. 
Through  the  intermediary  of  a  stethoscope  is  for  many  reasons 
the  more  suitable  method,  but  in  some  cases  it  may  be  impossible 
to  detect  the  sounds  for  which  we  are  listening  in  this  manner, 
whilst  if  the  ear  is  placed  directly  on  the  abdomen  they  are  readily 
heard.  A  binaural  stethoscope  is  the  best  form  to  use  with  thick 
rubber  tubes,  as  it  is  difficult  to  keep  a  straight  stethoscope  in 
position  over  an  enlarged  uterus.  In  all  cases  in  which  a 
stethoscope  is  used,  the  abdomen  must  be  bare  ;  but  if  the  ear 
is  applied  directly,  it  may  be  first  covered  with  a  thin  linen  or  silk 
handkerchief. 

By  listening  over  the  abdomen  of  a  pregnant  woman  a  number 
of  different  sounds  can  be  heard.  These  sounds  can  be  differen- 
tiated into  two  classes  : — 

(A)  Maternal  sounds. 

(B)  Foetal  sounds. 

Maternal  Sounds. — The  maternal  sounds  may  be  either 
produced  in  the  uterus  itself,  or  in  some  of  the  other  maternal 
organs.     They  are  as  follows : — 

(1)  The  Uterine  Souffle. — The  uterine  souffle,  or  the  uterine 
bruit,  is  a  blowing,  or  sibilant  sound  which  is  synchronous  with 
the  pulse  of  the  mother.  It  is  subject  to  great  ranges  of  alteration 
in  its  intensity,  length,  exact  character,  and  situations,  not  only 
in  different  patients,  but  in  the  same  patient  from  one  moment  to 
the  next.  It  has  been  said  that  the  true  souffle  of  pregnancy  has 
never  been  perfectly  imitated  in  any  other  condition  of  the  system 
(Naegele),  but  perhaps  the  sound  which  it  most  closely  resembles 
is  that  heard  over  a  varicose   aneurism  in    which    venous   and 

*  '  Evidences  of  Pregnancy,'  1833,  p.  121. 

f  '  Die  Geburtshiilfliche  Auscultation,'  1838,  p.  62. 

X  '  Traite  d'Auscultation  Obstetricale,'  1847. 


1 84  OBSTETRICAL  DIAGNOSIS 

arterial  blood  mix  (Montgomery).*  Its  character  is  not,  however, 
by  any  means  sufficiently  well  defined  to  enable  a  diagnosis  of 
pregnancy  to  be  based  upon  it.  When  the  uterus  commences  to 
contract,  the  souffle  becomes  louder,  and  then  gradually  diminishes 
as  the  contraction  reaches  its  height  until  it  becomes  almost  or 
quite  imperceptible.  As  the  contraction  passes  off,  the  souffle 
again  returns,  and,  when  the  contraction  has  ceased,  regains  its 
former  character.  At  one  time,  it  was  believed  that  the  souffle 
originated  in  the  placenta,  and  consequently  it  was  termed  the 
placental  souffle  (Monod,  Hohl).  This,  however,  has  been  long 
disproved,  inasmuch  as  it  is  not  loudest  over  the  placenta,  and  has 
been  heard  after  the  expulsion  of  the  latter.  Other  theories  have 
placed  the  murmur  in  the  aorta  and  iliac  vessels  (Bouillaud),  and 
in  the  epigastric  artery  (Kiwisch).  It  is,  however,  now  generally 
recognised  that  the  souffle  is  a  true  '  uterine  souffle '  and  is 
produced  in  the  ascending  branches  of  the  uterine  artery,  as  on 
any  other  hypothesis  it  would  be  difficult  or  impossible  to  explain 
the  effect  which  the  contractions  of  the  uterus  have  upon  its  char- 
acter. It  is  possible,  however,  that  a  small  contributory  souffle 
may  also  be  produced  in  some  of  the  neighbouring  viscera  or 
large  vessels.  It  is  also  possible  that  the  altered  character  of 
.the  blood  in  pregnancy  may  have  some  relation  to  the  produc- 
tion of  the  souffle,  in  the  same  manner  as  a  subclavian  bruit  is 
produced  in  anaemia.  Winckel  considers  that  the  souffle  is  pro- 
duced not  only  in  the  arteries  of  the  uterus,  but  also  in  the  veins, 
and  that  when  it  is  continuous  in  character  it  is  venous,  when 
intermittent,  arterial.  In  the  first  half  of  pregnancy,  the  souffle 
can  be  heard  best  in  the  middle  line  immediately  above  the 
symphysis  pubis;  In  the  latter  half,  it  can  be  heard  best  over 
the  lateral  aspect  of  the  lower  half  of  the  uterus,  and  particularly 
on  the  left  side  of  the  patient,  on  account  of  the  dextro-torsion  of 
the  uterus.  It  is  less  frequently  detected  over  the  fundus.  The 
souffle  is  first  heard  during  the  end  of  the  fourth  month — the 
sixteenth  week,  and  has  been  heard  up  to  ninety-nine  hours  after 
delivery.     It  can  also  be  heard  after  the  death  of  the  foetus  (Bailly). 

(2)  Cardiac  Sounds. — The  sounds  of  the  maternal  heart  can 
usually  be  distinctly  heard  over  the  uterus.  If  their  rate  is 
increased,  they  are  apt  be  to  mistaken  for  the  sounds  of  the 
foetal  heart.  To  obviate  this,  it  is  always  well  to  listen  to  the 
supposed  fcetal  heart  with  the  finger  on  the  maternal  pulse,  as 
any  considerable  difference  is  thus  easily  detected.  If  there  is  no 
apparent  difference  between  the  rate  of  the  supposed  fcetal  heart 
and  that  of  the  maternal  pulse,  each  should  be  counted  separately, 
and  by  this  means  confusion  will  be  avoided. 

(3)  Aortic  Pulse. — This  may  occasionally  be  heard  as  a  dull 
sound  synchronous  with  the  maternal  heart. 

(4)  Intestinal  Sounds. — Intestinal  sounds,  or  borborygmi,  due 

*  '  Signs  and  Symptoms  of  Pregnancy,'  by  W.  F.  Montgomery,  2nd  edit. 
London,  1856,  p.  214. 


AUSCULTATION  185 

to  the  movement  of  fluids  and   gases  in  the  intestines,  are  fre- 
quently heard.     They  cannot  be  confounded  with  any  other  sound. 

(5)  Respiratory  Sounds. — The  vesicular  murmur  of  the  mother 
may  be  transmitted  to  the  uterus,  and  cannot  infrequently  be 
heard  at  the  left  side,  especially  in  cases  of  dyspnoea. 

(6)  Friction  Sounds. — These  are  occasionally  heard,  and  are 
probably  produced  between  the  uterus  and  the  abdominal  wall  in 
cases  of  peritonitis. 

(7)  Crepitatory  Sounds. — These  are  crackling  or  bubbling 
sounds,  produced  either  inside  the  uterus  or  in  the  uterine  walls, 
and  are  most  frequently  the  result  of  putrefaction  of  the  foetus. 
They  may  also  arise  in  the  abdominal  wall  in  the  rare  instances 
of  emphysema  of  the  abdominal  wall,  due  to  the  presence  of 
gas-producing  bacteria. 

(8)  The  Muscular  Susurrus. — This  is  the  term  applied  to  a  dull 
note  given  out  by  contracting  muscle  fibre.  As  heard  over  the 
uterus,  it  is  produced  by  the  contractions  of  the  latter. 

Foetal  Sounds. — The  various  sounds  which  are  produced  by 
the  foetus  are  as  follows  : — 

(1)  Cardiac  Sounds. — The  foetal  heart  sounds  are  the  most 
important  of  all  the  auscultatory  phenomena.  They  are  double, 
and  closely  resemble  the  '  tic-tac '  of  a  watch  beating  beneath  a 
pillow.  Their  average  rate  is  140  per  minute,  and  the  highest 
and  lowest  rate  in  the  case  of  infants,  who  have  been  healthy  at 
birth,  is  respectively  160  and  120  (Depaul).*  On  the  other  hand, 
in  pathological  cases,  the  rate  has  fallen  as  low  as  60  per  minute 
(Pinard),  and  has  reached  a  rate  so  high  that  it  could  not  be 
counted.  Under  normal  circumstances,  the  rate  of  the  heart 
frequently  alters  within  a  short  space  of  time.  It  has  been  stated 
by  some  authorities  that  it  is  possible  to  determine  the  sex  of  a 
fcetus  by  ascertaining  the  average  rate  of  its  heart  (Franken- 
haiiser,  Ziegenspeck).  As,  however,  there  is  very  little  difference 
in  the  reputed  average  rate  of  the  two  sexes — 136  in  the  case  of  a 
male,  and  139  in  the  case  of  a  female  (Ziegenspeck) — the  difference, 
even  if  actual,  is  of  little  or  no  value  for  diagnostic  purposes.  It 
has  also  been  stated  that  the  rapidity  of  the  heart  is  in  inverse 
proportion  to  the  development  of  the  foetus.  The  weight  of  the 
latter  is  said  to  be  over  2,900  grammes  (6  lbs.  6  oz.),  when  the 
heart  beats  at  a  rate  of  129  per  minute,  and  under  this  figure 
with  more  frequent  pulsations.  However  this  may  be,  it  is 
sufficient  for  us,  as  practical  obstetricians,  that,  as  Winckel  says, 
'  the  foetal  cardiac  sounds  give  us  very  good  hints  as  to  the 
position,  presentation,  and  condition  of  the  child,  often  aid  in 
making  the  diagnosis  of  multiple  pregnancies,  and  warn  us  of 
impending  danger  to  the  child.' 

The  rate  of  the  foetal  heart  is  affected  by  the  occurrence   of 

*   '  Traite  d' Auscultation  Obstetricale.' 


186  OBSTETRICAL  DIAGNOSIS 

uterine  contractions,  active  fcetal  movements,  the  duration  of 
labour,  circulatory  disturbances— such  as  are  caused  by  pressure 
on  the  placenta  or  the  cord,  foetal  diseases — such  as  syphilis, 
and  such  diseases  of  the  mother  as  are  accompanied  by  elevation 
of  temperature.  The  effect  of  uterine  contractions  will  be  noted 
later.  Active  fcetal  movements  and  maternal  elevation  of  tem- 
perature increase  the  rate,  while  pressure  on  the  placenta  and 
cord  at  first  diminish  it,  then,  if  continued,  increase  it,  and 
finally,  if  sufficient  to  eventually  bring  about  the  death  of  the 
foetus,  again  diminish  it. 

The  site  at  which  the  fcetal  heart  is  best  heard  differs  according 
to  the  lie,  presentation,  and  position  of  the  foetus.     As  a  general 


Fig.    115.  —  Site    of    Maximum    Intensity   of   Fcetal   Heart-sounds   in 
Vertex  and  Pelvic  Presentations. 

i,  4,  First  vertex  presentation,  back  in  front  and  behind  ;  2,  3,  second  vertex 
presentation,  back  in  front  and  behind  ;  I,  IV,  first  pelvic  presentation, 
back  in  front  and  behind;  II,  III,  second  pelvic  presentation,  back  in 
front  and  behind. 

rule,  it  may  be  stated  that  it  is  best  heard  over  that  part  of  the 
foetal  trunk  which  is  nearest  to  the  heart,  and  which  is  in  contact 
with  the  anterior  uterine  wall.  The  site  of  maximum  intensity  in 
the  different  presentations  is  shown  in  the  accompanying  diagrams 
(v.  Figs.  115,  116),  and  will  be  referred  to  when  discussing  these 
presentations.  The  earliest  date  at  which  the  foetal  heart  can  be 
heard  is  usually  stated  to  be  at  or  about  the  eighteenth  week.  It 
may,  however,  be  further  stated  that  it  is  only  in  exceptionally 
favourable  cases,  and  by  an  obstetrician  possessed,  not  only  of 
keen  hearing,  but  of  considerable  skill  in  auscultation,  that  it  can 
be  heard  at  this  period.  It  may  be  well  to  add  that,  in  order  to  be 
certain  that  we  hear  the  fcetal  heart,  we  must  be  able  to  count  its 


AUSCULTATION  187 

rate,  in  order,  not  only  to  exclude  the  possibility  of  mistaking  the 
pulsations  of  the  maternal  heart  or  of  our  own  arteries  for  it,  but 
to  ensure  that  we  are  listening  to  a  definite  rhythmical  sound.  In 
this  connection,  we  may  be  permitted  to  recall  a  case  in  which 
Labatt  was  once  called  into  consultation,  and  in  which  the 
attending  physician  hesitated  to  extract  the  foetus  by  means  of  a 
crotchet  because  he  had  heard  the  foetal  heart.  On  a  further  ex- 
amination of  the  patient,  it  turned  out  that  she  was  not  pregnant. 
(2)  Funic  Souffle. — The  funic  souffle  is  a  blowing  sound,  which 
is  heard  in  certain  cases  on  listening  over  the  foetus,  and  which  is 
synchronous  with  the  foetal  heart.  Three  sites  at  which  it  may 
arise  have  been  suggested.     The  first  of  these  is  in  the  foetal  heart 


Fig.  116 — Site  of  Maximum  Intensity  of  Fcetal  Heart-sounds  in  Face 
and  Brow  Presentations. 

1,  Chin  to  right  and  behind  ;  2,  chin  to  left  and  behind  ;  3,  chin  to  left  and 
in  front ;   4,  chin  to  right  and  in  front  ;   5,  chin  to  right ;  6,  chin  to  left. 

— a  fcetal  endocardial  murmur  (Massman,  Ahlfeld).  Such  an 
occurrence  undoubtedly  does  occur  in  cases  of  intra-uterine  cardiac 
disease,  but  it  is  a  rare,  and  not  the  common,  cause  of  a  foetal 
souffle.  The  second  of  the  suggested  sites  is  in  the  vessels  of  the 
cord  at  the  umbilicus  (Hecker,  Schroeder) — an  umbilical  souffle. 
This  is  also  a  possible  site  of  production,  but  is  by  no  means  the 
invariable  one.  The  commonest  site  of  production  is  in  the 
umbilical  vein,  at  any  point  in  the  cord  at  which  the  flow  of 
blood  is  obstructed  (Evory  Kennedy,*  Winckel).  Such  obstruc- 
tion may  be  caused  by  tension,  as  where  the  cord  is  wound 
tightly  round  the  neck  of  the  foetus  ;  by  pressure,  as  where  the 
bell  of  the  stethoscope  compresses  the  funic  vessels  against  the 

*  Op.  cit.,  p.  122. 


1 88  OBSTETRICAL  DIAGNOSIS 

back  of  the  foetus ;  by  some  displacement,  resulting  in  an  incom- 
plete kinking  of  the  cord,  or  by  a  partial  obliteration  of  the  lumen 
of  the  funic  vessels.  In  the  last  case,  it  may  be  that,  as  is 
suggested  by  Pinard,  the  obstruction  is  caused  by  the  presence  of 
the  semilunar  folds,  which  have  been  noted  by  Hyrtl,  in  the 
interior  of  the  umbilical  vessels.  Tn  such  cases,  Pinard  suggests 
that  the  souffle  will  be  single  if  the  folds  occur  in  either  the  vein 
or  the  arteries,  and  that  it  will  be  double  if  they  occur  in  both. 
The  funic  souffle  is,  according  to  most  authorities,  heard  in  about 
ten  to  fifteen  per  cent,  of  cases  at  full  term.  Its  occurrence  is 
usually  considered  to  be  of  bad  import  for  the  foetus — a  point 
which  it  is  not  difficult  to  understand,  if  the  causation  of  the 
souffle  is  considered. 

(3)  Foetal  Movements. — The  foetal  movements  may  be  some- 
times heard  on  careful  auscultation.  They  occur  irregularly  as  a 
faint  tap  on  a  soft  surface,  or  as  a  dull  sound  resembling  the  beat 
of  the  aorta. 

Before  passing  on  to  the  last  method  of  obstetrical  diagnosis, 
it  will  be  well  to  discuss  the  relative  advantages  and  possibilities 
of  the  three  foregoing  methods  of  examining  a  pregnant  or 
parturient  woman— -i.e.,  abdominal  palpation,  vaginal  examination, 
and  auscultation-  -with  the  object  of  ascertaining  how  far  it  is 
possible  to  replace  internal  by  external  manipulations.  It  may 
be  at  once  said  that,  in  the  diagnosis  of  pregnancy  in  the  early 
months,  every  available  method  of  examination  is  required  ;  and 
as  at  this  period  the  difference  between  these  methods — so  far  as 
the  safety  of  the  patient  is  concerned — is  not  great,  we  shall  only 
concern  ourselves  with  the  comparison  of  the  different  methods  as 
used  during  parturition. 

By  means  of  abdominal  palpation,  we  can  determine  the  lie  and 
position  of  the  foetus,  and  in  a  great  number  of  cases  the  actual 
presentation.  Further,  we  can  follow  the  course  of  labour  by 
noting  the  descent  below  the  brim  of  the  presenting  part,  and  the 
rupture  of  the  membranes,  and  we  can  judge  of  the  effect  of  the 
duration  of  labour  on  the  uterine  muscle.  We  can  also  diagnose 
the  existence  and  nature  of  many  abnormalities  which  affect  the 
body  of  the  uterus  or  the  ovum,  and  the  existence  of  contracted 
pelvis  and  of  tumours  of  the  pelvis  which  project  above  the  brim. 

By  means  of  auscultation,  we  can  determine  the  condition  of 
the  foetus,  sometimes  recognise  the  presence  of  twins,  and  sup- 
plement the  information  which  abdominal  palpation  has  furnished 
regarding  the  position  and  lie  of  the  foetus. 

By  vaginal  examination,  we  can  determine  the  exact  presenta- 
tion and  lie  of  the  foetus,  and  in  most  cases  the  position.  Further, 
we  can  follow  the  course  of  labour  by  noting  the  descent  of  the 
presenting  part,  the  dilatation  of  the  cervix,  and  the  condition  of 
the  membranes.  We  can  also  diagnose  the  presence  of  such 
complications   as   presentation   of  the  funis  or  of  the  placenta, 


PELVIMETRY  189 

the  prolapse  of    a  limb,   or    the  existence  of   tumours  or    other 
pathological  conditions  of  the  cervix,  the  vagina,  or  the  pelvis. 

Accordingly,  it  is  evident  that  both  external  and  internal 
examination  afford  distinct  information,  and  that  neither  of  them 
can  be  dispensed  with.  In  practice,  however,  we  shall  find  that 
once  a  case  has  been  determined  to  be  normal,  so  far  as  the 
presentation  and  the  condition  of  the  pelvis  and  genital  passages 
are  concerned — and  for  this  purpose  one  vaginal  examination  in 
addition  to  abdominal  palpation  and  auscultation  is  all  that  is 
required,  vaginal  examinations  can,  as  a  rule,  be  dispensed  with, 
save  for  one  which  should  be  made  immediately  after  the  rupture 
of  the  membranes,  in  cases  in  which  the  head  was  not  fixed  when 
the  previous  examination  was  made.  The  reason  for  this  examina- 
tion is  to  make  certain  that  at  the  time  of  the  rupture  of  the 
membranes  the  funis  or  a  limb  has  not  been  swept  down  into 
the  vagina.  This  diminution  in  the  number  of  necessary  vaginal 
examinations  is  one  of  the  great  advances  of  modern  midwifery. 
It  is,  however,  only  rendered  possible  by  the  possession  of  a 
certain  degree  of  skill  in  the  practice  of  abdominal  palpation  and 
auscultation,  a  skill  which  it  is  the  duty  of  the  student  to  acquire 
by  practice  on  every  available  occasion.  It  must  not  be  thought 
that  external  manipulations  can  replace  internal  manipulations 
for  diagnostic  purposes  alone.  All  through  the  practice  of  mid- 
wifery, we  shall  see  that  an  obstetrician  who  has  acquired  skill  in 
abdominal  palpation  can,  in  many  instances,  substitute  external 
for  internal  manipulations,  either  in  great  part  or  altogether. 
This  is  a  point  of  no  small  importance.  No  matter  how  care- 
fully the  details  of  antiseptic  and  aseptic  midwifery  are  attended 
to,  there  is  always  a  risk  of  accidents  occurring,  and,  the  more 
frequently  internal  manipulations  are  performed,  the  more 
frequent  such  accidents  will  be.  Inasmuch  as  it  is  in  the  power 
of  every  student  to  acquire  skill  in  palpation  without  at  the  same 
time  increasing  the  risks  of  the  patient's  confinement,  there  is 
no  excuse  for  his  neglecting  his  opportunities.  It  is,  therefore, 
incumbent  on  him  to  practise  abdominal  palpation  and  ausculta- 
tion in  every  case  of  labour  in  which  he  has  the  opportunity. 


PELVIMETRY 

Pelvimetry  is  the  term  applied  to  the  measurement  of  the 
various  diameters  and  distances  of  the  pelvis.  It  is  a  method 
of  diagnosis  which  is  only  required  in  cases  in  which  the  history 
of  the  patient,  her  appearance,  or  the  information  furnished  by 
abdominal  palpation  or  vaginal  examination  lead  us  to  suspect 
the  existence  of  a  contracted  pelvis. 

In  order  to  be  able  to  recognise  the  particular  variety  of  con- 
tracted pelvis  with  which  we  are  dealing,  certain  measurements 
have  to  be  made.    These  measurements  fall  under  two  headings  : — 


190 


OBSTETRICAL  DIAGNOSIS 


external  measurements  and  internal  measurements,  and  are  as 
follows : — 

I.  External  Measurements. 

(1)  The  distance  between  the  anterior  superior  spines  of 

the  ilium. 

(2)  The  distance  between  the  most  distant  portions  of  the 

iliac  crests. 

(3)  The  external  conjugate,  or  Baudelocque's  diameter — 

i.e.,  the  distance  between  the  upper  margin  of  the 
symphysis  and  the  depression  under  the  spinous 
process  of  the  last  lumbar  vertebra. 

(4)  The  distance  between  the  posterior  superior  spines. 

(5)  The  transverse  diameter  of  the  outlet — i.e.,  the  distance 

between  the  tubera  ischii. 

(6)  The  antero-posterior  diameter  of  the  outlet — i.e.,  the 

distance  between  the  tip  of  the  coccyx  and  the  lower 
margin  of  the  symphysis. 

(7)  The  distance  between  the  trochanters. 

II.  Internal  Measurements. 

(1)  The  true  conjugate — i.e.,  the  distance  between  the  pro- 

montory of  the  sacrum  and  the  most  prominent  part 
of  the  back  of  the  symphysis. 

(2)  The  oblique  conjugate — i.e.,  the  distance  between  the 

promontory  of  the  sacrum  and  the  lower  margin  of 
the  symphysis. 

(3)  The  transverse   diameter — i.e.,   the   greatest   distance 

between  the  lateral  margins  of  the  brim. 

External  Pelvimetry. — The  different  external  measurements 
can  be  ascertained  by  means  of  some  of  the  many  modifications 


Fig.  117. — Martin's  Pelvimeter  for  External  Measurements. 


of  Baudelocque's  pelvimeter.  Martin's  modification  is,  perhaps, 
the  most  serviceable  and  the  least  cumbersome  to  carry 
(v.  Fig.  117).  The  method  of  using  it  does  not  require  much 
explanation.     To    measure   the   distances   between    the    anterior 


EXTERNAL  PELVIMETRY 


191 


superior  iliac  spines,  the  iliac  crests,  or  the  trochanters,  the 
patient  lies  on  her  back  with  her  legs  close  together,  while  the 
examiner  stands  or  sits  below  the  level  of  the  hips  and  facing 
her.  He  then  takes  the  pelvimeter  in  both  hands,  holding  the 
extremities  of  the  limbs  between  his  thumb  and  middle  finger 
as  shown  in  Fig.  118,  and  with  the  index  fingers  determines  the 
exact  position  of  the  points  on  which  the  instrument  is  to  rest. 
The  tips  of  the  instrument  are  then  placed  on  these  points,  and 


Fig.   118. — External  Pelvimetry:  Measuring  External  Conjugate 

of  Pelvis. 

E,  Depression  under  spine  of  last  lumbar  vertebra  ;  C,  centre  of  symphysis. 

the  distance  between  them  read  off  on  the  scale.  To  measure 
the  external  conjugate  the  patient  lies  on  her  side  with  her  back 
turned  towards  the  operator.  The  instrument  is  held  as  before, 
and  one  limb  is  pressed  firmly  into  the  depression  beneath  the 
spine  of  the  last  lumbar  vertebra,  while  the  other  is  placed  on 
the  upper  margin  of  the  symphysis.  If  the  depression  below  the 
lumbar  spine  cannot  be  found  owing  to  excessive  fat,  its  position 


192 


OBSTETRICAL  DIAGNOSIS 


may  be  determined  by  taking  the  middle  of  a  line  between  the 
two  pits  which  mark  the  posterior  superior  spines,  and  then 
measuring  a  centimetre  upwards  (Crede),  or  by  taking  a  point 
in  the  middle  line  three  to  four  centimetres  below  the  level  of 
the  iliac  crests  (Spiegelberg).  To  measure  the  distance  between 
the  posterior  superior  spines,  the  patient  lies  on  her  side  or  on 
her  face,  and  the  tips  of  the  pelvimeter  are  applied  to  the 
depressions  which  mark  the  positions  of  the  spine.  To  measure 
the  distance  between  the  tubera  ischii,  the  patient  must  be  placed 
in  the  lithotomy  position,  the  positions  of  the  inner  margin  of  the 
tuberosities  of  the  ischium  are  marked  with  a  pencil  on  the  skin 
overlying  them,  and  the  distance  between  them  measured  with 
a  tape  measure.     To  the  result  one  to  two  centimetres  (0*4  to  o-8 


Fig.  119.— External  Pelvimetry:  Measuring  Transverse  Diameter 

of  Outlet. 

TT',  Inner  margins  of  tubera  ischii. 


inch)  must  be  added  to  make  up  for  the  thickness  of  the  soft  parts. 
Another  method  consists  in  palpating  the  inner  margin  of  the 
tubera  ischii  with  the  thumbs,  and  then  so  placing  the  latter  that 
the  nails  are  directly  over  the  points  to  be  measured  (Franken- 
hauser).  An  assistant  then  ascertains  the  distance  between  the 
nails  with  a  pelvimeter  with  the  blades  crossed  (v.  Fig.  119).  To 
measure  the  antero-posterior  diameter  of  the  outlet,  the  patient 
is  placed  on  her  side  with  her  back  towards  the  operator.  The 
position  of  the  sacro-coccygeal  joint  is  determined  by  passing  the 
index  finger  into  the  vagina  and  palpating  the  intervening  tissue 
between  it  and  the  thumb  placed  over  the  termination  of  the 


INTERNAL  PEL  VIMETR  Y 


193 


sacrum  externally.  One  terminal  of  the  pelvimeter  is  then  placed 
on  this  point,  and  the  other  on  the  sub-pubic  ligament  of  the 
symphysis  (v.  Fig.  120).  From  the  measurement  thus  obtained 
a  deduction  of  one  to  one  and  a  half  centimetres  (0-4  to  o*6  inch) 
must  be  made  to  compensate  for  the  thickness  of  the  sacro- 
coccygeal joint  (Breisky).* 

The  value  of  the  measurements  obtained  in  this  manner  for 
diagnostic  purposes  is  not  very  great,  as  will  be  presently  seen. 
Still,  in  certain  cases  they  are  of  assistance,  and  should  be  made. 

Internal  Pelvimetry. — The  measurements  of  the  internal 
diameters  of  the  pelvis  are  very  much  more  important  than  are 


Fig.    120.  —  External    Pelvimetry  :     Measuring    Anteroposterior 
Diameter  of  Outlet. 

O,  Sacro-coccygeal  joint ;  C,  lower  margin  of  symphysis. 


those  of  the  external,  as  they  furnish  us  with  an  exact  plan  of  the 
size  of  the  canal  through  which  the  foetus  has  to  pass  ;  they  are, 
however,  at  the  same  time,  very  much  more  difficult  to  determine 
correctly.  The  important  diameters  are  the  true  conjugate  and 
the  transverse  diameter  of  the  brim.  The  oblique  conjugate  is 
only  measured  for  the  purpose  of  obtaining  a  basis  from  which  to 
estimate  the  true  conjugate. 


Wien.  Med.  Jahrbuch,  1870,  Part  I.,  p   3. 


li 


194 


OBSTETRICAL  DIAGNOSIS 


There  are  three  methods  of  ascertaining  the  length  of  the  true 
conjugate : — ■ 

(i)  By  direct  measurement  with  the  fingers. 

(2)  By  measuring  the  oblique  conjugate  with  the  fingers  and 

then  estimating  the  true  conjugate  from  it. 

(3)  By  direct  measurement  with  an  internal  pelvimeter. 


Fig.   121. — Internal  Pelvimetry:  Johnson's  Method. 
A,  Conjugate,  measuring  four  inches  ;  B,  conjugate,  measuring  three  and  a 
half  inches  ;   C,  conjugate,  measuring  three  and  a  quarter  inches  ;  D,  con- 
jugate,  measuring  three  inches.     (These  measurements   are  those   of  a 
man's  hand  of  average  size.) 

Direct   Measurement   with    the   Fingers.  —  This    method   was 
introduced  so  long  ago  as  the  eighteenth  century  by  Johnson,* 
but  as  it    can    only  be  practised  after  delivery — i.e.,   when  the 
*  '  A  System  of  Midwifery,'  by  R.  W.  Johnson,  London,  1769. 


INTERNAL  PELVIMETRY 


195 


vaginal  walls  are  very  lax,  or  in  cases  of  great  antero-posterior 
narrowing  of  the  pelvis — its  value  is  not  very  great.  For  this 
reason,  it  is  not  necessary  to  describe  it  at  any  length.  Shortly 
stated,  it  consists  in  so  arranging  the  fingers  and  thumb  of  one 
hand  that  they  will  just  fill  the  space  between  the  promontory  of 
the  sacrum  and  the  symphysis,  and  then  in  measuring  the  width 
of  the  hand  in  such  a  position*  (v.  Fig.  121). 

Indirect  Measurement  with  the  Fingers. — This  method  consists 
in  first  measuring  the  oblique  conjugate  as  will  be  described, 
and  then,  after  making  certain  necessary  allowances,  estimating 
from  this  the  length  of  the  true  conjugate.  It  is  a  method  of  value 
when  practised  by  an  expert  who  has  had  considerable  experi- 
ence ;  but,  in  view  of  the  difficulty  of  making  correct  allowances 
for  the  various  factors  which  have  to  be  taken  into  consideration,  it 


Fig.  122. — Effect  of  False  Pro- 
montory at  Junction  of  First 
and  Second  Pieces  of  Sacrum, 
C,  on  the  True  Conjugate 
Diameter  C  V. 


Fig.  123. — The  Effect  of  the 
Height  of  the  Promontory 
on  the  Relation  between  the 
True  and  the  Oblique  Con- 
jugate Diameters. 


does  not  yield  very  reliable  results  in  the  hands  of  a  comparatively 
unskilled  person.  To  measure  the  oblique  conjugate,  the  patient 
is  placed  in  the  dorsal  position  with  her  buttocks  slightly  raised 
by  means  of  a  pillow  placed  beneath  them.  The  index  and 
middle  fingers  are  then  introduced  into  the  vagina  and  passed 
upwards  until  the  promontory  is  reached.  The  first  step  consists 
in  ascertaining  whether  there  is  a  false  promontory  or  not,  as,  in 
certain  cases,  a  false  lumbar  promontory  is  formed  at  the  junction 
of  the  fourth  and  fifth  lumbar  vertebrae,  or  a  false  sacral  promon- 
tory at  the  junction  of  the  first  and  second  pieces  of  the  sacrum 
(v.  Fig.  122).     The  true  promontory  is  readily  recognised  by  the 

*  A  full  description  of  Johnson's  method  will  be  found  in  Herman's  work 
on  '  Difficult  Labour,'  p.  176. 

13—2 


196 


OBSTETRICAL  DIAGNOSIS 


fact  that  the  outline  of  the  anterior  margin  of  the  base  of  the 
sacrum  starts  from  it.  In  some  forms  of  contracted  pelvis,  the 
distance  between  the  false  promontory  and  the  symphysis  may 
be  less  than  the  distance  between  the  true  promontory  and  the 


Fig.  124.- 


Tnternal  Pelvimetry  :  Measuring  Oblique  Conjugate 
with  the  Fingers. 


symphysis  (Crede),*  and,  in  such  cases,  the  less  diameter  must  be 
taken  as  representing  the  true  conjugate,  and  our  measurements 
made  accordingly.  Having  ascertained  the  point  from  which  the 
measurement  is  to  be  made,  the  tip  of  the  middle  finger  is  placed 
on  it,  and  then  the  hand  is  raised  until  the  sub-pubic  ligament  is 


Fig.  125. — The  Effect  of  the  Inclination  of  the  Symphysis  on  the 
Relation  between  the  True  and  the  Oblique  Conjugate 
Diameters. 

in  contact  with  its  radial  edge  (v.  Fig.  124).     The  spot  at  which 

the  ligament  crosses  this  edge  is  then  marked,  by  making  a  small 

indent   with   the   finger-nail,   the   hand   is   withdrawn,  and   the 

*  Crede,  '  Klin.  Vortrage  liber  Geburtshtilfe,'  Berlin,  1853. 


INTERNA  L  PEL  VIMETR  Y 


197 


distance  between  the  tip  of  the  middle  finger  and  the  mark  is 
measured.  The  measurement  should  be  repeated  a  couple  of 
times  in  order  to  ensure  accuracy.  If  it  is  difficult  to  reach 
the  promontory  owing  to  its  high  situation,  the  elevation  of  the 
buttocks  is  slightly  increased,  and  the  patient  is  desired  at  the 
same  time  to  press  her  lumbar  spine  firmly  on  to  the  bed.  By 
this  means  the  angle  which  the  plane  of  the  brim  makes  with 
the  horizontal  plane  of  the  bed  is  increased,  and  the  promontory 
is  brought  nearer  to  the  examining  finger  (Schaeffer).* 

Having  in  this  manner  ascertained  the  length  of  the  oblique 
conjugate,  the  next  thing  is  to  estimate  from  it  the  true  conjugate. 
As  will  be  seen  by  reference  to  a  diagram  of  a  pelvis,  the  oblique 


Fig.  126. — Effects  of  Alterations  in  Symyphysis  of  Thickness  A), 
and  of  Depth  (B)  on  Relation  between  the  True  and  the 
Oblique  Conjugate  Diameters. 


conjugate  in  normal  pelves  is  longer  than  the  true  conjugate.  The 
average  difference  in  normal  pelves  between  the  two  is  about  half 
an  inch ;  but,  in  contracted  pelves,  there  are  so  many  factors  which 
affect  the  relation  of  these  diameters  to  one  another,  that  it  is  not 
sufficient  to  allow  for  an  average  difference,  and  an  attempt  must 
be  made  to  judge  what  is  the  exact  difference.  This,  however,  is 
by  no  means  any  easy  matter.  Anyone  can  measure  the  oblique 
conjugate  sufficiently  correctly,  but  it  requires  considerable  ex- 
perience to  enable  one  to  attach  a  correct  value  to  the  various 
factors  which  alter  the  normal  relations  between  it  and  the  true 
conjugate.     These  various  factors  are  as  follows  : — 

(1)  The  Height  of  the  Promontory. — The  higher  the  promontory, 
the  greater  is  the  difference  between  the  true  and  the  oblique 

*  Schaeffer,    'Obstetric    Diagnosis   and    Treatment.'      American   edition, 
p.  61. 


198  OBSTETRICAL  DIAGNOSIS 

conjugate  ;    the  lower  the  promontory,    the    less   the   difference 
(v.  Fig.  123). 

(2)  The  Inclination  of  the  Symphysis.  —  The  more  vertical  the 
symphysis,  the  greater  is  the  difference  between  the  two  conju- 
gates ;  the  more  horizontal  the  symphysis,  the  less  the  difference 
(v.  Fig.  125). 

(3)  The  Depth  of  the  Symphysis.  —  The  deeper  the  symphysis, 
the  greater  is  the  difference  between  the  two  conjugates ;  the 
shallower  the  symphysis,  the  less  the  difference  (v.  Fig.  126  b). 

(4)  The  Thickness  of  the  Symphysis. — The  thicker  the  symphysis, 
the  greater  is  the  difference  between  the  two  conjugates  ;  the 
thinner  the  symphysis,  the  less  the  difference  (v.  Fig.  126  a). 

There  is  one  point  in  favour  of  this  method  of  estimating  the 
true  conjugate,  and  that  is  that  in  the  form  of  contracted  pelvis, 


|i'3f':  |J:  ■'',    '     ''     '     "    |-1      "   ",'■    "J   "   ':'   '  '  "   "   ?     V.1   '-  -!-  '-  '''  '^  'JJJ .  >  "   ''■"  J'"'"  "•■-"..■'i?.',i"i°.[  (_, 

Fig.  127. — Skutsch's  Internal  Pelvimeter. 
A,  Complete  pelvimeter  ;  B,  flexible  limb  ;  C,  metal  rule. 

in  which  it  is  most  necessary  to  measure  the  true  conjugate — viz., 
a  fiat  pelvis — the  average  distance  between  the  two  conjugates  is 
usually  correct  (Herman).*  However,  even  if  it  is  possible  to 
measure  the  true  conjugate  correctly  with  the  fingers,  it  is  im- 
possible to  measure  the  transverse  diameter  of  the  brim.  For 
this  reason,  we  have  usually  to  resort  to  the  third  method  of 
performing  internal  pelvimetry — direct  measurement  with  an  in- 
ternal pelvimeter. 

Direct  Measurement  with  an  Internal  Pelvimeter. — This  is 
the  only  reliable  manner  in  which  to  measure  all  the  required 
diameters  of  a  contracted  pelvis.  If  a  little  care  is  taken  to 
master  its  details,  it  presents  no  difficulties,  and  after  a  little 
experience  it  will  be  found  to  give  reliable  results.  It  is  curious 
that    so    many  text-books  on  midwifery  should   either   omit   all 

*  Op.  cit.,  p.  176. 


INTERNAL  PELVIMETRY  199 

mention    of    the    method,    or    merely    mention    it   as   a   form    of 
obstetrical  curiosity. 

The  best  form  of  internal  pelvimeter — indeed,  the  only  form 
which,  so  far  as  we  know,  permits  the  measurement  of  the  trans- 
verse diameter— is  that  devised  by  Skutsch.:;:  This  instrument  con- 
sists of  three  parts  : — (a)  a  rigid  limb  ;  (b)  a  flexible  limb  ;  (c)  a 
movable  connecting  bar  (v.  Fig.  127).  The  two  limbs  interlock  by 
means  of  an  adjustable  joint,  which  enables  the  rigid  limb  to  be 
so  placed  that  its  convexity  is  either  turned  towards  or  away  from 
the  flexible  limb.  The  connecting-bar  is  not  graduated  in  any 
way  ;  it  merely  serves  as  a  means  by  which  the  limbs  can  be 
fixed  in  any  desired  relation  to  one  another,  and  can  be  separated 
and  returned  to  the  same  relation  as  required.     In  order  to  use 


Fig.  128.— Internal    Pelvimetry  :   Measuring   Obstetrical   Conjugate 
plus  Thickness  of  Symphysis  and  Superjacent  Soft  Parts. 

the  instrument,  the  patient  is  placed  in  the  cross-bed  dorsal 
position,  or  on  a  gynaecological  couch.  In  most  cases,  an  anaes- 
thetic is  required,  as  the  procedure  causes  a  certain  amount  of 
pain.  A  small  patch  of  skin  over  the  symphysis  is  then  shaved, 
and  a  mark  is  made  with  a  blue  pencil  over  the  centre  of  the  sym- 
physis. The  principle  on  which  Skutsch's  mode  of  pelvimetry 
is  based  is  a  very  simple  one.  In  every  case,  the  required 
diameter,  plus  the  thickness  of  the  pelvic  wall  and  the  superjacent 
soft  parts  at  one  end  of  the  diameter,  is  first  measured.  Then 
the  thickness  of  the  included  pelvic  wall  and  soft  parts  are 
measured,  and  by  deducting  this  result  from  the  former,  the 
actual  measurement  of  the  diameter  is  obtained.     To  measure 

*  '  Die  Beckenmussen,'  Jena,  1886  ;  and  '  Die  Praktische  Verwerthung  der 
Beckenmussen,'  Deutsche  Med.  Wocli.,  1891,  No.  21. 


OBSTETRICAL  DIAGNOSIS 


the  true  conjugate,  the  pelvimeter  is  first  so  arranged  that  the 
rigid  limb  curves  away  from  the  flexible  limb,  and  then,  by  means 
of  the  movable  connecting-bar,  the  limbs  are  so  locked  that  they 
make  an  angle  of  about  6o°  with  one  another.  The  index  and 
middle  fingers  of  the  left  hand  are  then  passed  into  the  vagina, 
and  upwards  until  the  tip  of  the  middle  finger  rests  on  the 
promontory.  The  rigid  limb  of  the  pelvimeter  is  passed  into  the 
vagina  under  the  guidance  of  these  fingers,  and  its  tip  brought 
to  rest  on  the  most  projecting  part  of  the  promontory  (v.  Fig.  128.) 
The  vaginal  fingers  hold  it  in  this  position  with  the  external 
assistance  of  the  other  hand,  while  an  assistant  bends  the  flexible 
limb  downwards  until  it  just  touches  the  mark,  which  was  made 
over  the  centre  of  the  symphysis.  The  instrument  is  then  care- 
fully withdrawn,  and  the  distance  between  the  ends  measured  with 


Fig. 


129.- 


-Internal  Pelvimetry  :  Measuring  Thickness  of  Symphysis 
and  Superjacent  Soft  Parts. 


the  metal  rule,  and  noted.  The  position  of  the  rigid  limb  is 
then  altered,  so  that  it  curves  towards  the  flexible  limb,  the 
fingers  of  the  left  hand  are  again  passed  into  the  vagina,  and  the 
back  of  the  symphysis  carefully  palpated  with  the  object  of 
determining  its  most  projecting  part.  The  tip  of  the  rigid  limb 
is  then  guided  into  the  vagina,  and  rested  against  this  point,  and 
the  flexible  limb  is  again  bent  down  until  the  tip  just  touches  the 
marked  spot  (v.  Fig.  129).  As  there  is  a  certain  amount  of  risk 
that  the  relations  between  the  ends  of  the  pelvimeter  may  be 
altered  by  the  pressure  of  the  soft  parts  during  its  withdrawal,  it 
is  well  to  open  the  thumbscrew  which  is  at  one  end  of  the  con- 
necting-bar, and  then  to  separate  the  limbs  as  far  as  is  necessary. 
As  soon  as  the  instrument  has  been  taken  out  of  the  vagina,  the 


INTERNAL  PELVIMETRY 


limbs  are  brought  back  into  their  original  position — a  procedure 
which  is  rendered  possible  by  the  presence  of  a  small  collar  at 
one  end  of  the  connecting-bar,  which  acts  as  a  check  to  the 
range  of  movement  of  the  limbs,  and  the  distance   between  the 


Fig.  130. — Internal  Pelvimetry  :  Measuring  Transverse  Diameter  of 
Brim  plus  Thickness  of  Lateral  Wall  of  Pelvis  and  Superjacent 
Soft  Parts. 

tips  is  measured.  This  distance  is  then  subtracted  from  the 
first  measured  distance,  and  the  result  is  the  length  of  the  true 
conjugate  diameter. 

To  measure  the  transverse  diameter,  a  mark  is  made  over  one 


Fig.  131. — Internal   Pelvimetry  :    Measuring   Thickness    of    Lateral 
Wall  of  Pelvis  and  Superjacent  Soft  Parts. 

or  other  great  trochanter,  and  the  pelvimeter  is  so  adjusted  that 
the  rigid  limb  curves  away  from  the  flexible  limb.  If  the  mark 
has  been  made  over  the  left  trochanter,  the  fingers  of  the  right 
hand  are  passed  into  the  vagina,  and  the  right  lateral  half  of  the 


202  OBSTETRICAL  DIAGNOSIS 

brim  of  the  pelvis  is  carefully  palpated  with  the  object  of  ascer- 
taining the  starting-point  on  that  side  of  the  transverse  diameter. 
The  tip  of  the  rigid  limb  is  then  guided  on  to  this  point  and  held 
there,  while  an  assistant  bends  down  the  flexible  limb  until  the 
tip  rests  upon  the  mark  over  the  trochanter  (v.  Fig.  130).  The 
instrument  is  then  carefully  withdrawn,  and  the  distance  between 
the  tips  measured.  The  rigid  limb  is  then  reversed,  the  left 
fingers  are  passed  into  the  vagina,  and  the  left  half  of  the  pelvic 
brim  is  palpated  as  before,  and  with  the  same  object.  The  tip 
of  the  rigid  limb  is  then  guided  on  to  the  left  end  of  the  trans- 
verse diameter,  and  the  flexible  limb  bent  downwards  again  on  to 
the  mark  (v.  Fig.  131).  The  instrument  must  be  opened  to  permit 
of  its  withdrawal,  and,  after  removal  and  closure,  the  distance 
between  the  tips  is  measured.  This  distance  is  subtracted  from 
the  former  measurement,  and  the  result  is  the  length  of  the  trans- 
verse diameter. 

Both  diameters  should  be  measured  two  or  three  times  until  a 
satisfactory  result  is  arrived  at.  In  the  case  of  the  transverse 
diameter,  it  is  well  to  measure  first  from  one  trochanter,  and  then 
from  the  other,  as  in  this  way  an  additional  check  on  the  measure- 
ment is  obtained.  There  are  three  points  which  must  be  care- 
fully attended  to  in  using  Skutsch's  pelvimeter.     These  are  : — 

(a)  To  ascertain  the  correct  terminations  of  the  different 
diameters  by  careful  preliminary  internal  examination  of  the  pelvic 
brim. 

(b)  To  bring  the  end  of  the  rigid  limb  to  rest  exactly  on  these 
spots,  and  to  keep  it  there  while  the  external  limb  is  being 
adjusted. 

(c)  To  see  that  the  assistant  places  the  end  of  the  flexible 
limb  exactly  on  the  external  mark  in  each  case,  and  that  the  end 
always  presses  on  the  skin  with  the  same  degree  of  force.  The 
latter  point  will  be  best  obtained  by  always  bringing  the  tip  down 
so  that  it  just  touches  the  skin  without  dimpling  it. 


PART    III 
THE    PHYSIOLOGY   OF    PREGNANCY 


CHAPTER  I 
THE  MATERNAL  PHENOMENA  OF  PREGNANCY 

Duration  of  Pregnancy — The  Phenomena  of  Pregnancy.  Changes  in  the 
Uterus  ;  in  the  Cervix ;  in  the  Fallopian  Tubes  and  Ovaries ;  in  the 
Vagina  and  Vulva ;  in  the  Pelvic  Floor  ;  in  the  Abdominal  Wall ;  in  the 
Bladder  and  Rectum  ;  in  the  other  Abdominal  Organs  ;  in  the  Thorax  ; 
in  the  Breasts ;  in  the  Face  and  Limbs  ;  in  the  Pelvic  Joints  :  Systemic 
Changes,  Circulatory  System,  Respiratory  System,  Urinary  System, 
Digestive  System,  Osseous  System. 

Pregnancy  is  the  term  applied  to  the  condition  of  a  woman  when 
she  contains  within  her  the  products  of  conception.  It  com- 
mences with  the  fertilisation  of  the  ovum,  and  ends  with  its 
expulsion.  It  is  customary  to  consider  that  the  duration  of 
pregnancy  is  ten  lunar  months  of  four  weeks  each,  or  280  days, 
counting  from  the  first  day  of  the  last  menstruation.  In  practice, 
however,  we  find  that  considerable  divergence  from  this  period  is 
often  met  with.  When  we  consider  the  various  factors  associated 
with  the  occurrence  of  conception,  this  divergence  is  easily  under- 
stood. The  chief  of  these  factors  are  the  time  at  which  the 
fertilising  coitus  takes  place,  the  preparedness  of  the  uterus  for 
the  reception  of  the  fertilised  ovum,  and  the  time  at  which  ovula- 
tion takes  place.  The  human  species  differs  from  animals  in 
that  in  the  human  female  there  is  no  period  of  sexual  inactivity, 
consequently  the  fertilising  coitus  may  occur  at  any  time  in 
relation  to  menstruation,  save  when  menstruation  is  actually  taking 
place.  Similarly,  the  uterus  is  apparently  always  in  a  favourable 
condition  for  the  reception  of  the  impregnated  ovum  at  all  times 
save  when  menstruation  is  occurring.  Ovulation,  on  the  other 
hand,  is  considered  to  occur  most  usually  during  the  week  before 
or  the  week  after  menstruation,  on  account  of  the  attendant  con- 
gestion of  the  generative  organs.  Consequently,  it  is  probable 
that  the  most  favourable  time  for  impregnation  to  occur  is  in  the 
week  preceding  or  the  week  following  a  menstrual  period  (Giles). 
In  practice,  however,  even  if  the  date  of  the  fertilising  coitus  is 
known,  it  is  difficult  to  determine  when  delivery  will  occur.  The 
following  table  of  Reid's,  based  on  the  results  of  forty  cases  in 
which  only  a  single  coitus  took  place,  shows  the  truth  of  this : — 

205 


206 


THE  PHYSIOLOGY  OF  PREGNANCY 


Number  of  Cases. 

Duration  of 

Pregnancy  in 

Days. 

Percentage. 

5  "         "         " 

7     -        -        -  -      - 
18     -       '-         -        - 

6  -          -         -         - 
4     - 

260-266 

267-273 
274-280 
281-287 
288-294 

125 
I7-5 
45  "o 
15-0 
100 

The  results  which  are  obtained  by  counting  from  the  date  of 
the  last  menstruation  are  not  much  more  satisfactory.  The 
following  table  shows  the  results  in  650  cases  collected  by  Merri- 
man  and  Reid.  In  each  case  pregnancy  is  calculated  from  the 
final  day  of  the  last  menstruation  : — 


Duration  of 

Number  of  Cases. 

Pregnancy  in 

Percentage. 

Days. 

43o 

28      -         -         -         - 

253-259 

64      -          -         -         - 

260-266 

9-84 

102      -         -         .         - 

267-273 

15-69 

177     - 

274-280 

2723 

140     - 

281-287 

2i'53 

81      -          -         -         - 

288-294 

12*46 

39     - 

295-301 

600 

13     ....      . 

302-308 

2x0 

6     -         -         -         - 

309-315 

0-92 

The  average  duration  of  pregnancy,  calculated  from  a  large 
series  of  cases,  and  counting  from  the  final  day  of  the  last  men- 
struation, is  277  days.  Between  that  period  and  a  period  of 
280  days,  counting  from  the  first  day  of  the  last  menstruation, 
there  is  not  much  difference,  and  the  former  is  the  more  easy  to 
remember. 


THE  PHENOMENA  OF  PREGNANCY 

From  the  commencement  of  pregnancy  many  pronounced 
changes  begin  to  occur  in  the  maternal  system,  affecting  more 
particularly  the  reproductive  organs,  and  also  to  a  less  extent 
almost  every  other  organ  in  the  body.  Many  of  these  changes 
are  the  direct  result  of  the  increased  blood-supply  which  the 
pelvic  viscera  receive,  and  of  the  mechanical  effects  exercised 
upon  neighbouring  parts  by  the  growing  uterus ;  others  must  be 
associated  with  the  necessity  of  supplying  the  enlarging  ovum 
with  oxygen  and  nutritive  material ;  while  still  others  cannot  be 


CHANGES  IN  THE  UTERUS  207 

referred  to  any  of  these  causes,  and  must  be  classed  as  signs  of  the 
profound  physiological  alteration  which  has  occurred  in  the  entire 
organism.     The  changes  will  be  considered  seriatim. 

The  Uterus.  —  The  anatomical  changes  which  take  place  are 
more  marked  in  this  organ  than  in  any  other,  since  it  must 
rapidly  enlarge  to  provide  an  adequate  receptacle  for  the  ovum. 
The  entire  extent  of  the  change  which  occurs  can  best  be  appre- 
ciated by  comparing  the  weight  and  capacity  of  the  viscus  when 
in  the  pregnant  and  non-pregnant  condition.  The  weight  of  the 
unimpregnated  virgin  uterus  is  about  an  ounce ;  that  of  the  uterus 
at  term  is  about  two  pounds,  or  thirty-two  times  as  heavy.  The 
capacity  at  term  is  increased  even  out  of  proportion  to  this,  being 
from  4,000  c.c.  to  5,000  c.c,  or  nearly  five  hundred  times  as 
great  as  in  the  virgin. 

All  the  tissues  of  the  uterus  share  in  this  hypertrophy.  The 
mucous  membrane  becomes  softer  and  thicker,  attaining  a  thick- 
ness of  about  half  an  inch  at  the  fifth  month  ;  the  glands  become 
elongated,  tortuous,  and  very  much  dilated;  and  at  the  same  time 
the  important  changes  which  were  described  in  discussing  the 
formation  of  the  placenta*  are  brought  about  in  the  blood-supply. 
The  muscular  tissue  in  the  earlier  months  undergoes  an  enormous 
hypertrophy,  so  that,  in  spite  of  the  rapid  increase  in  size  of  the 
entire  organ,  its  walls  still  maintain  their  original  thickness.  At 
first,  the  uterus  grows  more  rapidly  than  the  foetus,  but  in  the 
later  months  the  ovum  increases  in  size  out  of  proportion  to  the 
uterus,  and  some  slight  degree  of  thinning  of  the  uterine  walls 
then  takes  place  as  a  result  of  the  distension.  The  increase  in 
the  muscular  tissue  is  partially  due  to  increase  in  size  of  the 
individual  fibres,  and  partly  to  the  development  of  new  fibres 
(v.  Fig.  132).  Scattered  amid  the  fibres  of  the  non-gravid  uterus 
are  found  a  large  number  of  embryonic  cells,  which,  under  the 
stimulus  of  pregnancy,  become  developed  into  true  muscular 
fibres,  and  these,  as  well  as  what  may  be  termed  the  permanent 
muscle  fibres,  attain  an  enormous  degree  of  development,  becoming 
often  ten  times  as  large  as  an  ordinary  unstriped  muscle  cell. 
The  connective  tissue  undergoes  hypertrophy  pari  passu  with  the 
muscular  tissue,  and  thus  enables  the  various  layers  of  the 
muscular  coat  to  be  more  easily  demonstrated — in  fact,  it  is 
principally  in  the  walls  of  the  gravid  uterus  that  these  layers 
have  been  described.  The  hypertrophy  of  the  muscle  elements 
at  first  takes  place  throughout  the  entire  uterus,  but,  after  the 
third  month^  the  body  and  fundus  alone  show  signs  of  increase, 
the  cervix  having  at  that  time  reached  its  maximum  develop- 
ment. The  peritoneum  covering  the  uterus  also  shares  in  the 
general  hypertrophy,  and,  instead  of  becoming  thinner,  shows 
signs  of  thickening,  at  any  rate  in  the  earlier  months.  The  con- 
nective tissue  immediately  subjacent  to  it  also  becomes  thicker 

*  For    further    details   concerning   formation    and   fate    of    decidua,    see 
page  83. 


io8 


THE  PHYSIOLOGY  OF  PREGNANCY 


over  the  lower  portion  of  the  uterus,  and  especially  in  front.  Over 
the  fundus  and  back,  however,  the  serous  coat  remains  very 
closely  adherent  to  the  muscular  wall. 

The  uterine  and  ovarian  arteries,  but  especially  the  former, 
become  elongated,  their  lumen  greatly  increased  in  size,  and  their 
coats  thicker.  The  increase  in  size  is  most  pronounced  in  the 
branches  which  are  distributed  over  the  placental  site.  The 
branches,  which  have  been  described  as  passing  vertically  inwards, 
assume  a  spiral  form,  and,  together  with  the  veins,  are  subject  to 
compression  during  contraction  of  the  uterus,  owing  to  the  manner 
in  which  the  fibres  of  the  middle  layer  of  the  muscular  coat 
surround  them.     The  veins  also  become  dilated,  particularly  in 


Fig.   132. — Uterine  Muscle  Fibres. 

Embryonic  muscle  fibres  of  non-pregnant  uterus;  3,  4, 
from  pregnant  uterus.     (Galabin.) 


5,  muscle  fibres 


the  neighbourhood  of  the  placental  site.  Commencing  in  the 
maternal  blood  sinuses  of  the  placenta,  they  pass  into  the  uterine 
wall,  where  they  form  what  are  known  as  the  uterine  sinuses. 
These  sinuses  are  large  venous  spaces,  whose  wall  is  practically 
formed  by  the  uterine  tissue,  a  thin  layer  of  endothelium  alone 
intervening.  From  these,  the  veins  pass  into  the  broad  ligament, 
from  which  the  blood  is  carried  off  by  the  uterine  and  ovarian 
veins.  The  ovarian  veins  are  enormously  distended,  especially 
on  the  left  side,*  where  this  vessel  may  attain  a  diameter  almost 
equal  to  that  of  the  femoral  vein.     The  uterine  veins  are  also 

*  This  is  irrespective  of  the  position  of  the  placenta. 


CHANGES  IN  THE  UTERUS 


209 


distended,  but  appear  to  drain  away  less  of  the  blood  from  the 
uterus  than  the  ovarian  veins.  This  is  probably  due  to  the  large 
development  of  the  fundus  uteri,  and  to  the  usually  high  position 
of  the  placenta. 

The  lymphatics  of  the  uterine  wall  increase  in  number  and 
size,  and  probably  play  an  important  part  in  providing  for  the 
nutrition  and  excretion  of  the  foetus  before  the  formation  of  the 
placental  circulation. 

The  nerves  also  enlarge,  and  the  ganglion  cervicis  is  said  to 
become  almost  double  its  former  size. 

In  the  first  three  months  of  pregnancy,  the  increase  in  size  of 
the  uterus  affects  its  breadth  and  thickness  more  than  its  length, 


Fig.   133. — Sagittal  Mesial  Section  of  a  Patient  who  Died  in  the 
Second  Month  of  Pregnancy. 

The  body  of  the  uterus  is  retroflected,  and  if  the  patient  had  lived  incarcera- 
tion might  have  occurred.     (Braune.) 


so  that  the  globular  shape  which  it  gradually  assumes  becomes 
an  important  sign  in  the  early  diagnosis  of  pregnancy,  and  can 
readily  be  detected  by  bi-manual  examination.  The  increased 
weight  of  the  uterus  causes  it  at  the  same  time  to  sink  a  little 
deeper  in  the  pelvis,  and  brings  about  an  exaggeration  of  its 
normal  degree  of  anteflexion.  This  sinking  occasionally  causes 
disagreeable  pressure  symptoms  in  the  first  period  of  gestation  by 

14 


210  THE  PHYSIOLOGY  OF  PREGNANCY 

pressing  on  the  bladder  and  rectum,  and  upon  the  veins  of  the 
latter.  It  may  also  cause  a  retro-deviated  uterus  to  pass  more 
deeply  into  the  concavity  of  the  sacrum,  thereby  increasing  the 
subsequent  difficulty  in  clearing  the  sacral  promontory.  This 
sinking  also  causes  the  abdominal  wall  just  above  the  symphysis 
to  become  rather  flatter  during  the  first  couple  of  months  after 
conception  than  it  is  at  other  times. 

About  the  commencement  of  the  fourth  month,  the  fundus  of 
the  uterus  reaches  the  level  of  the  pelvic  brim,  and  from  that  time 
on  it  gradually  ascends  higher  and  higher  into  the  abdomen.  The 
globular  shape  is  retained  until  the  sixth  month,  but,  after  that 
date,  the  rapid  growth  of  the  ovum  causes  the  latter  to  assume  a 


Fig.  134. 


-Sagittal  Mesial  Section  of  a  Primipara  who  Died  during 
the  Fourth  Month  of  Pregnancy.     (Waldeyer.) 


position  in  the  uterus  with  its  long  axis  corresponding  to  the 
vertical  axis  of  that  viscus.  In  this  way,  the  uterus  is  made  to 
assume  an  ovoid  shape,  the  broad  end  of  which  is  formed  by  the 
fundus,  and  the  narrow  end  of  which  is  situated  at  the  junction 
of  the  body  with  the  cervix. 

As  the  uterus  ascends  into  the  abdomen,  it  over-rides  the  lower 
part  of  the  mesentery  proper,  and  ultimately  flattens  out  the 
entire  mesentery  against  the  posterior  abdominal  wall,  driving 
the  small  intestine  over  to  the  left,  and  upwards  beneath  the 
transverse  meso-colon.  The  uterus  itself,  as  a  result  of  the 
position  of  the  small  intestines,  almost  invariably  inclines  towards 


CHANGES  IN  THE  CERVIX  211 

the  right,  and  lies  in  contact  with  the  right  antero-lateral  wall  of 
the  abdomen.  In  addition  to  this  obliquity,  its  long  axis  frequently 
shows  also  a  marked  rotation  to  the  right,  which  brings  its  left 
margin  in  contact  with  the  anterior  abdominal  wall,  and  its  right 
margin  into  relation  with  the  front  of  the  right  kidney  and 
ascending  colon.  Sometimes,  but  very  rarely,  the  uterus  occupies 
a  median  position,  or  is  inclined  to  the  left,  and  a  rotation  of  its 
long  axis  to  the  left  has  also  been  described. 

Owing  to  the  pelvic  inclination,  the  uterus  is  directed  forwards 
as  it  passes  into  the  abdomen,  and  therefore  in  the  erect  position 
is  largely  supported  by  the  anterior  abdominal  wall  and  by  the 
symphysis  pubis.  In  the  recumbent  position,  though  retaining 
its  anteversion,  it  becomes  retroflexed,  and  is  supported  by  the 
structures  on  the  posterior  abdominal  wall.  When  relaxed,  its 
weight  causes  it  to  become  flattened  from  before  backwards  and 
to  bulge  out  at  the  sides,  and  it  then  becomes  impressed  by  the 
various  viscera  with  which  it  is  in  contact.  It  must  be  remem- 
bered, however,  that,  during  pregnancy,  the  uterus  is  constantly 
undergoing  a  series  of  slow  contractions,  and  that,  consequently, 
its  form  is  but  little  dependent  on  the  pressure  of  surrounding 
structures. 

According  to  Sutugin*  and  Galabin,!  the  following  is  the 
average  height  of  the  uterus  above  the  pubes  at  the  different 
months  : — 

Week    of    preg- 
nancy    -         -    16,    18,    20,    22,    24,    26,    28,    30,    32,   34,    36,    38,    40. 

Height  of  uterus 
in  inches         -  40,  47,  54,  60,  66,  73,  78,  83,  87,  90,  9/3,  96,  100. 

One  point  will  immediately  strike  the  reader  in  this  table, 
namely,  that  there  is  no  decrease  shown  in  the  height  of  the 
uterus  above  the  pubis  at  the  end  of  the  tenth  month.  This  is 
accounted  for  by  Galabin  on  the  ground  that  these  measurements 
were  taken  with  the  patient  in  the  horizontal  position,  and  that 
the  sinking  of  the  fundus  is  only  appreciable  when  the  patient  is 
in  the  erect  position. 

The  Cervix. — The  changes  which  take  place  in  the  cervix  uteri 
during  pregnancy  have  for  long  been  the  subject  of  controversy, 
and  as  many  points  have  not  yet  been  definitely  decided  upon,  it 
is  unnecessary  here  to  enter  at  any  length  into  a  discussion  of  the 
matter,  more  especially  since  some  of  the  points  at  issue  are 
merely  verbal  ones.  The  alterations  that  take  place  will  be  dealt 
with  under  three  headings  : — 

(1)  Changes  in  position. 

(2)  Changes  in  consistence. 

(3)  Changes  in  length. 

*   'On  the  Means   of  Ascertaining  the  Length  of  Gestation,'  etc.,  Obstet. 
jfourn.  of  Great  Britain  and  Ireland,  vol.  iii.,  1875. 
f  Op.  cit.,  p.  141. 

14 2 


212  THE  PHYSIOLOGY  OF  PREGNANCY 

(i)  Changes  in  Position: — Associated  with  the  general  descent 
of  the  uterus,  the  cervix  descends  somewhat  during  the  first  three 
months  of  pregnancy,  and  is  felt  at  a  lower  level  than  normal 
within  the  vagina,  and  projecting  slightly  forwards.  After  the 
end  of  the  third  month,  it  is  gradually  drawn  upwards  by  the 
ascending  uterus,  and  sometimes  to  such  an  extent  that  difficulty 
may  be  experienced  in  detecting  it  by  vaginal  examination.  The 
anteversion  which  is  normally  present  becomes  changed  into 
retroversion,  and  often  the  long  axis  of  the  cervix  forms  a  well- 
marked  angle,  open  forwards,  with  the  axis  of  the  body  of  the 
uterus. 

(2)  Changes  in  Consistence  : — From  the  end  of  the  first  month, 
a  well-marked  change  in  the  consistence  of  the  cervix  can  be 
detected  by  the  examining  finger,  and  forms  an  important 
diagnostic  sign.  The  most  superficial  portion  of  the  lips  of  the 
os  externum  first  become  soft  and  oedematous,  due  to  the  vascular 
and  lymphatic  hypertrophy,  and  to  an  outpouring  of  serous  fluid 
from  the  enlarged  bloodvessels.  This  softening  gradually  extends 
to  the  deeper  parts  of  the  cervix,  till  at  the  end  of  the  third  month 
the  whole  of  the  infravaginal  portion  is  thus  altered.  During  the 
succeeding  months,  the  change  extends  upwards  ;  and,  finally,  at 
the  end  of  pregnancy  the  whole  cervix — unless  it  be  the  seat  of 
pathological  change — has  become  soft  and  dilatable.  The  soften- 
ing in  the  region  of  the  os  externum  enables  the  finger  to  be  more 
readily  passed  between  its  lips  into  its  cavity,  and  gives  an 
impression  as  if  the  orifice  itself  were  circular. 

(3)  Changes  in  Length  .•—Until  comparatively  recently  it  was 
taught  that  the  upper  portion  of  the  cavity  of  the  cervix  became 
gradually  distended  during  pregnancy  from  above  downwards  to 
form  the  lower  uterine  segment,  and  that  this  method  of  inclusion 
accounted  for  the  shortening  of  the  cervix  which  was  believed  to 
occur.  This  view,  in  spite  of  some  opposition,  was  held  till  the 
middle  of  the  last  century  ;  and  most  books  on  midwifery  gave 
definite  details  as  to  the  amount  of  shortening  which  one  might 
expect  to  find  at  the  different  months  of  pregnancy.  However, 
since  then  several  observers — chief  among  whom  in  this  country 
was  Matthews  Duncan* — have  affirmed  that  no  taking  up  of 
the  cervix  occurs  till  a  very  short  period  before  the  onset  of 
labour,  and  that,  instead  of  being  shortened,  the  cervix  is  actually 
lengthened.  This  opinion  is  now  generally  believed  to  be  the 
correct  one,  and  is  arrived  at  from  the  result  of  actual 
measurements  of  the  cervix  made  during  dissections  of  uteri  at 
the  different  months.  It  was,  however,  strongly  combated  by 
Bandl,f  who,  from  a  study  of  a  series  of  sections  and  specimens, 
re-annunciated  in  1877  the  old  view  in  a  slightly  modified  form. 

*  G.  Matthews  Duncan,  'On  the  Cervix  Uteri  in  Pregnancy,'  Edinburgh 
Medical  Journal,  1859. 

t  Bandl,  L.,  '  Ueber  das  Verhalten  des  Uterus  und  Cervix  in  der  Schwan- 
genschaft  und  wahrend  der  Geburt.'     Stuttgart. 


CHANGES  IN  THE  CERVIX 


213 


He  stated  it  to  be  his  belief  that  the  upper  portion  of  the  cervix 
did  open  out,  and  that  the  prominent  ring,  which  may  sometimes 
be  felt  in  the  uterine  wall  during  labour  above  the  symphysis 
pubis,  represented  the  os  internum.  One  chief  obstacle  to 
accepting  his  views  is  that  the  lower  part  of  the  uterine  cavity 
is  lined  with  decidua,  but   this  he  explained   by   stating  that  it 


OE 


OE 


Fig.   135. 


-Diagram  showing  the  Two  Views  held  regarding  the 
Formation  of  the  Lower  Uterine  Segment. 


The  left-hand  diagram  (A)  represents  the  view  generally  received,  according 
to  which  the  retraction  ring  marks  the  junction  between  the  upper  and 
lower  uterine  segment  and  does  not  correspond  with  the  inner  os.  The 
right-hand  diagram  (B)  represents  the  views  held  by  Bandl,  according  to 
which  the  inner  os  and  Bandl's  ring  coincide,  and  the  lower  segment  is 
formed  out  of  the  taken-up  cervix.  RR,  retraction  ring  ;  CC,  cervical 
cavity  ;  LS,  lower  uterine  segment ;  OI,  os  internum  ;  OE,  os  externum. 
(After  Dickinson.) 

grows  down  from  the  body  of  the  uterus,  and  displaces  the 
cervical  mucous  membrane  before  it  into  the  closed  part  of  the 
cervix.  Since  the  publication  of  Bandl's  papers  a  considerable 
amount  of  investigation  has  been  carried  out,  and  the  fact  that  no 
taking  up  of  the  cervical  canal  occurs  has  been  demonstrated 
by  a  number  of  observers.  The  ring  to  which  Bandl  called 
attention,  and   which   is    sometimes    known   by   his   name,   un- 


214 


THE  PHYSIOLOGY  OF  PREGNANCY 


doubtedly  does  not  represent  the  os  internum,  but  is  the  line 
of  separation  which  marks  off  the  upper  contractile  from  the 
lower  non-contractile  segment  of  the  corpus  uteri.  It  cannot  be 
clearly  seen  in  the  uterus  after  death,  and  is  evidently  produced 
by  the  contraction  and  retraction  which  occurs  during  labour. 
The  walls  of  the  uterus  before  the  onset  of  labour  are  of 
practically  the  same  thickness  from  the  fundus  down  to  the  level 
of  the  closed  cervix,  where  a  sudden  increase  in  thickness  takes 
place.  Externally,  there  is  a  sharp  line  of  demarcation  visible 
and  palpable  between  the  cervix  and  the  body  ;  and  above  this 
level  no  other  ring  can  be  seen,  with  the  exception  of  a  faint 


Fig.  136. — Diagram  showing  Direction  of  Cervical  Axis  before  (A) 

AND    (B)    DURING    PREGNANCY. 

u.  Uterus;  v,  vagina;  b,  bladder.     (Galabin.) 


constriction  on  the  anterior  wall,  corresponding  to  the  line  of 
reflection  of  the  peritoneum  on  to  the  symphysis  pubis.  This 
ring  is  therefore  non-existent  before  labour  commences,  and 
must  be  regarded  as  being  produced  within  the  body  of  the 
uterus  itself,  as  a  result  of  the  peculiar  mode  in  which  the 
corpus  uteri  contracts.  That  the  cervix  is  really  lengthened 
has  also  been  amply  demonstrated  ;  and  the  apparent  shortening 
which  is  felt  by  the  finger  when  making  a  vaginal  examina- 
tion may  be  explained  as  follows  : — («)  The  softening  of  the 
cervical  tissues  permits  the  finger  to  compress  them,  and  to 
enter  for  a  short  distance  through  the  os  externum,  which  has 


CHANGES  IN  THE  LIGAMENTS  215 

become  somewhat  patulous.  (b)  The  vaginal  wall  has  become 
softened  and  cedematous  at  its  uterine  attachment,  and  this, 
combined  with  the  gradual  ascent  of  the  cervix,  which  ascent 
occurs  from  the  fourth  month  onwards,  causes  the  projection 
of  the  portio  vaginalis  into  the  vagina  to  feel  and  to  be  really 
shorter,  without  any  change  having  taken  place  in  the  length  of 
the  cervix  as  a  whole,  (c)  The  downward  bulging  of  the  cavity 
of  the  uterus  in  front  of  the  cervix  as  a  result  of  the  pressure 
of  the  foetal  head,  together  with  a  forward  inclination  of  the 
cervix  from  above  downwards,  render  the  apparent  shortening 
of  the  anterior  lip  and  cervical  wall  particularly  noticeable,  inas- 
much as  these  conditions  cause  the  vertical  distance  between  the 
uterine  cavity  and  the  os  externum  to  be  really  lessened.  The 
forward  inclination  of  the  cervix,  in  fact,  causes  the  examining 
finger  to  be  separated  from  the  cavity  of  the  uterus  by  the 
antero-posterior  thickness,  and  not  by  the  length  of  the  cervix 
(v.  Fig.  136). 

Fallopian  Tubes  and  Ovaries. — The  Fallopian  tubes  participate 
in  the  hypertrophy  of  the  uterus,  becoming  longer  and  wider. 
They  lie  closely  applied  to  the  uterine  wall,  and  their  direction  is 
altered  so  that  their  long  axis  becomes  almost  vertical.  The 
ovaries  lie  immediately  external  and  posterior  to  the  tubes,  and 
are  also  closely  related  to  the  side  of  the  uterus.  Their  level  in 
the  abdominal  cavity  is  about  that  of  the  anterior  spines  of  the 
ilia.  In  consequence  of  the  axial  rotation  of  the  uterus,  the  left 
ovary  is  brought  forwards  into  contact  with  the  anterior  abdominal 
wall,  and  the  right  lies  posteriorly  in  contact  with  the  caecum. 
Both  ovaries  are  enlarged,  and  contain  true  corpora  lutea. 

Ligaments  and  Peritoneal  Reflections  of  Uterus.  —  Reference 
has  already  been  made  to  the  hypertrophy  of  the  serous  coat  of 
the  uterus,  and  we  have  now  only  to  consider  its  reflections  off 
the  uterus.  On  the  posterior  aspect,  the  level  of  reflection  of  the 
peritoneum  on  to  the  rectum  remains  unchanged,  and  is  opposite 
the  fifth  sacral  vertebra.  Anteriorly,  however,  it  is  considerably 
raised,  and  in  the  later  months  of  pregnancy  passes  directly  from 
the  front  of  the  uterus,  over  the  top  of  the  bladder,  to  the  back  of 
the  symphysis  pubis  about  its  middle,  thus  substituting  a  utero- 
pubic  for  the  normal  utero-vesical  pouch.  The  broad  ligaments 
also  are  raised.  As  the  uterus  expands  upwards  and  laterally,  it 
increases  the  tension  upon  these  ligaments,  and  at  the  same  time 
burrows  out  between  their  folds.  The  upper  attachment  of  the 
ligaments  to  the  uterus  remains  the  same  as  before,  but  their 
lower  attachment  is  displaced  upwards  to  the  iliac  fossae.  Ulti- 
mately, they  assume  an  elongated  triangular  shape,  the  apex  being 
situated  at  the  junction  of  the  Fallopian  tubes  with  the  uterus, 
and  the  base  in  the  iliac  fossae,  where  the  folds  which  constitute 
the  ligaments  pass  forwards  and  backwards,  in  continuity  with  the 
peritoneum  lining  the  fossae. 

The  intra-abdominal  portions  of  the  round  ligaments  are  very 


216  THE  PHYSIOLOGY  OF  PREGNANCY 

much  thickened.  Superiorly,  they  appear  attached  to  the  anterior 
rather  than  the  lateral  aspect  of  the  uterus,  in  consequence  of  the 
lateral  expansion  of  that  viscus.  From  their  uterine  attachment, 
they  pursue  an  almost  vertical  course  downwards  parallel  and 
internal  to  the  Fallopian  tubes,  and  are  closely  bound  to  the 
uterus  till  just  before  they  reach  the  internal  abdominal  ring. 
No  increase  in  size  of  these  ligaments  is  found  within  the  inguinal 
canal.  Their  enlargement  within  the  abdomen  enables  them 
from  their  attachment  below  to  draw  the  fundus  uteri  forwards, 
and  bring  the  long  axis  of  the  uterus  more  into  a  line  with  the 
axis  of  the  pelvic  brim  during  labour. 

The  Vagina  and  Vulva.  — During  the  early  months  of  pregnancy 
the  vagina  becomes  wider  and  shorter  in  consequence  of  the 
sinking  of  the  uterus ;  but  the  subsequent  ascent  of  the  latter 
exerts  an  upward  pull  upon  the  vagina,  which,  consequently, 
from  the  end  of  the  third  month  becomes  longer  and  narrower 
than  normal.  The  muscular  tissue  of  its  wall  hypertrophies,  and 
the  mucous  membrane  becomes  thicker,  more  relaxed,  and  of  a 
bluish  colour.  This  colour  is  the  expression  of  the  venous 
engorgement  of  the  vaginal  walls,  brought  about  by  the  intra- 
abdominal pressure,  and  by  the  enormous  hypertrophy  and 
dilatation  of  the  veins  of  the  vaginal  plexus.  The  mucous  mem- 
brane of  the  vulva  also  becomes  softer  and  relaxed,  and  the 
vulvar  orifice  widened.  Some  dilatation  and  hypertrophy  of 
the  superficial  veins  occur,  but  little  change  is  noticeable  in 
the  erectile  tissue  proper.  The  connective  tissue  surrounding 
both  vulva  and  vagina  becomes  increased  in  amount  and  softened, 
and  a  similar  change  occurs  throughout  the  whole  of  the  pelvic 
cellular  tissue. 

Pelvic  Floor. — The  pelvic  floor,  in  common  with  the  abdominal 
wall,  shows  the  increased  pressure  which  is  thrown  upon  it  during 
pregnancy  by  an  increased  projection  beyond  the  plane  of  the 
pelvic  outlet.  In  the  non-pregnant,  this  projection  is  about  an  inch 
(2-5  centimetres)  ;  at  the  end  of  pregnancy  it  is  about  3f  inches 
(9/5  centimetres).  The  distance  from  the  coccyx  to  the  symphysis, 
measured  along  the  surface,  is  correspondingly  increased.  In  the 
non-pregnant,  this  distance  is  about  5§  inches  (13*5  centimetres), 
and,  at  the  end  of  pregnancy,  it  reaches  as  much  as  ioi  inches 
(25-5  centimetres).  The  muscles  of  the  pelvic  dia.phva.gm(kvator 
ani  and  coccygeus)  do  not  present  any  hypertrophy,  but  all  the 
involuntary  muscular  tissue  within  the  pelvis  is  increased.  The 
obliterated  hypogastric  arteries  hypertrophy,  and  bands  of  un- 
striped  muscle  extend  from  their  upper  and  lower  margins  on 
to  the  antero-lateral  aspect  of  the  uterus,  forming  a  somewhat 
hammock-like  support  around  the  lower  uterine  segment. 

Abdominal  Wall. — The  first  change  noticed  in  the  abdominal 
wall  as  a  result  of  pregnancy  is  slight  flattening  just  above  the 
symphysis  pubis,  brought  about  by  the  primary  downward 
sinking   of   the   uterus   and   its  contents.     Before,  however,  the 


CHANGES  IN  THE  BLADDER  AND  RECTUM  217 

uterus  actually  extends  into  the  abdominal  cavity,  evidence  of  the 
increased  abdominal  content  is  seen  in  a  gradually  increasing 
protuberance  of  the  abdominal  wall.  The  exact  amount  of  this 
protuberance  depends  on  the  period  of  pregnancy,  and  varies 
with  the  form  of  the  individual.  The  umbilical  scar  becomes 
gradually  raised  up,  and  reaches  the  level  of  the  surrounding 
skin  at  the  sixth  or  seventh  month.  Later,  it  becomes  completely 
everted,  and  projects  above  the  general  surface,  surrounded  by  a 
pigmented  area  of  skin,  which  has  been  called  by  Montgomery" 
the  '  umbilical  areola.'  A  pigmented  line  of  a  brownish  colour — 
the  depth  of  hue  varying  with  the  complexion  of  the  individual — 
also  forms  between  the  umbilicus  and  pubes.  It  is  usually 
broader  below  than  above,  and  may  extend  above  the  umbilicus 
as  far  as  the  ensiform  cartilage.  It  fades  considerably  after 
delivery,  but  traces  of  it  frequently  remain  permanent.  In  some 
cases,  the  pressure  on  the  anterior  abdominal  wall  causes  wide 
separation  of  the  recti  muscles,  and,  if  the  uterus  is  unusually 
anteflexed,  it  may  even  form  a  hernial  protrusion  between  their 
inner  borders. 

The  stretching  of  the  abdominal  wall  affects  the  nutrition  of  the 
skin,  and  in  the  later  months  of  pregnancy  pinkish  or  bluish 
marks — the  lineae  atrophica?,  or  striae  gravidarum — make  their  ap- 
pearance principally  on  the  lateral  aspect  of  the  lower  portion  of 
the  abdomen.  The  lines  are  usually  curved,  with  their  concavity 
inwards,  and  are  broader  at  the  centre  than  at  either  end.  After 
delivery,  they  assume  a  white  colour,  and  are  slightly  depressed 
below  the  level  of  the  surrounding  skin.  Similar  marks  may 
appear  upon  the  outer  aspect  of  the  thighs  in  their  upper  part. 

Bladder  and  Rectum. — As  the  uterus  ascends  into  the  abdomen, 
the  peritoneum  is  gradually  stripped  off  the  posterior  and 
superior  surfaces  of  the  bladder,  so  that  this  viscus  in  the  later 
months  becomes  entirely  stripped  of  peritoneum.  Its  capacity  is 
diminished,  and  when  empty  it  is  found  flattened  out  between  the 
lower  segment  of  the  uterus  and  the  back  of  the  symphysis,  and 
is  triangular  in  shape.  The  apex  is  directed  upwards,  lying  at  a 
point  about  half  an  inch  below  the  upper  margin  of  the  symphysis  ; 
the  base  is  directed  downwards,  and  rests  on  the  anterior  vaginal 
wall,  just  in  front  of  the  utero- vaginal  junction.  The  bladder 
walls  are  slightly  thickened.  The  ureters  enter  the  bladder  on 
each  side  of  its  base.  Within  the  pelvis,  the  relations  of  the 
ureter  are  quite  unaltered,  and  it  is  in  no  way  subjected  to  in- 
jurious pressure.  In  the  abdomen,  however,  the  right  ureter  is 
compressed  between  the  relaxed  uterus  and  the  right  psoas  muscle 
when  the  patient  is  in  the  recumbent  position.  It  would  appear 
as  if  the  yielding  nature  of  both  these  structures  would  render 
this  pressure  practically  ineffectual,  but  that  this  is  not  the  case 
is  proved  by  the  fact  that  the  right  ureter  is  dilated  during  preg- 
nancy. Within  the  pelvis,  both  ureters  are  hypertrophied.  They 
*  Montgomery,  '  Signs  and  Symptoms  of  Pregnancy,'  p.  96,  1856. 


2i8  THE  PHYSIOLOGY  OF  PREGNANCY 

become  round  and  cord-like,  with  greatly  thickened  walls,  and 
in  the  terminal  part  of  their  course  can  readily  be  felt  and 
compressed  against  the  ramus  of  the  pubis  by  the  finger  when 
making  a  vaginal  examination. 

Owing  to  the  forward  bending  of  the  uterus  and  the  obliquity 
of  the  pelvic  brim,  very  little  direct  pressure  is  exerted  upon  the 
rectum.  The  deviation  of  the  uterus  to  the  right  side,  moreover, 
causes  the  pelvic  and  iliac  colon  to  escape,  so  that,  except  under 
abnormal  conditions,  no  obstruction  of  the  lower  bowel  can  occur 
from  pressure.  Evidence  of  the  general  venous  congestion  of  the 
pelvic  organs  is,  however,  seen  in  the  rectum  in  the  frequent 
presence  of  haemorrhoids. 

Other  Abdominal  Organs. — The  position,  which  the  intestines 
are  compelled  to  take  by  the  enlarging  uterus,  has  already  been 
referred  to,  and  it  may  now  be  added  that  the  transverse  colon 
passes  transversely  across  the  upper  margin  of  the  full-term 
uterus.  The  transverse  meso- colon  is  hollowed  out  to  receive  the 
fundus.  When  in  the  recumbent  posture,  the  uterus  lies  in  direct 
contact  with  the  lower  portion  of  the  anterior  surface  of  the  right 
kidney,  and  over  this  area  the  fatty  capsule  of  the  kidney  is 
deficient  —  a  fact  which  may  partly  account  for  the  greater 
frequency  of  movable  kidney  on  this  side.  This  kidney  also  often 
occupies  a  slightly  lower  position  than  normal,  due  probably  to 
the  downward  pressure  of  the  liver.  The  left  kidney  and  the 
suprarenal  capsules  are  quite  unaltered. 

The  vertical  depth  of  the  anterior  part  of  the  liver  is  diminished 
by  the  upward  pressure  of  the  uterus,  which  is  only  separated 
from  it  by  the  transverse  meso-colon,  and  a  compensatory  increase 
in  the  vertical  depth  of  the  posterior  part  occurs,  and  possibly 
tends  to  displace  the  right  kidney  downwards. 

The  Thorax. — The  mechanical  effects  of  the  pressure  of  the 
enlarged  uterus  are  not  confined  to  the  abdominal  and  pelvic 
cavities,  but  also  affect  to  a  somewhat  variable  extent  the  thoracic 
cavity.  The  vertical  height  of  the  latter  is  diminished  in  cor- 
respondence with  the  increased  vertical  height  of  the  peritoneal 
cavity,  and  this  change  is  most  marked  on  the  right  side.  In  fact, 
the  liver  is  pushed  bodily  upwards,  and  the  right  dome  of  the 
diaphragm  often  reaches  as  high  as  the  seventh  dorsal  vertebra. 
On  the  left  side,  also,  there  is  slight  elevation  of  the  cupola  of  the 
diaphragm.  The  diminution  in  capacity  of  the  thorax,  which  this 
decrease  in  vertical  extent  tends  to  bring  about,  is  amply  com- 
pensated by  the  widening,  which  takes  place  at  the  same  time 
at  its  base. 

The  Breasts. — The  close  physiological  connection  which  exists 
between  the  mammary  glands  and  the  uterus  is  shown  by  the 
early  appearance  of  changes  in  the  breasts  following  upon  con- 
ception. As  early  as  the  end  of  the  second  month,  a  feeling  of 
uneasiness  and  fulness  of  the  breasts,  with  perhaps  occasional 
shooting  pains,  is  experienced,  and  at  the  same  time  they  begin 


CHANGES  IN  THE  BREAST  219 

to  enlarge.  The  gradual  increase  in  size  continues  till  term,  and 
sometimes  is  so  great  as  to  cause  pressure  atrophy  of  the  skin 
along  certain  lines  radiating  irregularly  from  the  nipple,  and 
similar  to  those  described  as  found  upon  the  abdominal  wall. 

The  increase  in  size  of  the  breast  is  due  to  a  slight  extent  to 
the  hypertrophy  of  the  adipose  and  connective  tissue,  but  is 
principally  the  result  of  the  increase  in  size  of  the  existing  acini, 
and  of  the  budding  out  of  new  secreting  acini.  These  changes 
cause  the  breast  to  feel  harder,  and  to  become  knotty  and 
irregular.     The  outlying  masses  of  the  gland  can  also  be  more 


Fig.  137. — The  Mammary  Areola  at  the  Third  Month  of  Pregnancy. 

(Montgomery.) 

distinctly  felt.  The  increased  blood-supply  associated  with  these 
changes  is  manifested  by  the  enlargement  of  the  superficial  veins, 
which  can  be  plainly  seen  as  bluish  lines  on  the  surface. 

Most  important  changes  from  a  diagnostic  point  of  view  occur 
in  the  neighbourhood  of  the  nipple.  The  nipple  itself  becomes 
more  prominent  and  elevated  above  the  surface.  Its  summit  is 
somewhat  flattened  and  directed  downwards,  and  it  tends  more 
readily  when  stimulated  to  become  turgid  with  blood.  The 
earliest  change  noticed  in  the  areola  is  an  enlargement  of  the 
tubercles — Montgomery's  follicles* — with  which  its  surface  is 
studded,  and  a  slight  moistening  of  the  skin  from  such  of  those 

*  Montgomery,  '  Signs  and  Symptoms  of  Pregnancy,'  p.  165,  1856. 


220  THE  PHYSIOLOGY  OF  PREGNANCY 

as  are  formed  by  accumulations  of  sebaceous  glands  (v.  Fig.  137). 
From  the  third  month  onwards,  a  gradual  deepening  in  colour  of 
the  pigment  contained  within  the  cells  of  its  integument  can  be 
observed,  and  the  areola  itself  becomes  widened.  The  depth  of 
hue  varies  from  a  light  brown  to  an  almost  complete  black,  and 
the  extent  of  change  is  usually  greater  in  primiparae  than  in 
women  who  have  borne  many  children,  since  in  the  latter  a 
permanently  darker  tint  is  often  retained.     The  areola  shares  also 


Fig.   138. — The  Mammary  Areola  at  the  Ninth  Month  of  Pregnancy. 

(Montgomery.) 

in  the  turgescence  of  the  nipple.  Surrounding  it  for  an  area  of 
an  inch  or  more,  there  appears  about  the  fifth  month  a  ring,  over 
which  are  seen  numerous  round  spots  or  whitish  mottled  patches, 
'  presenting  an  appearance  as  if  the  colour  had  been  discharged 
by  a  shower  of  drops  falling  upon  the  part.'  This  area  has  been 
called  the  secondary  areola.  Montgomery,*  who  first  drew  atten- 
tion to  it,  regarded  it  as  exclusively  resulting  from  pregnancy,  and 
therefore  of  extreme  importance  as  a  diagnostic  sign. 

Preparation  for  the  secretion  of  milk  is  made  within  the  gland 
*  Montgomery,  op.  cit. 


SYSTEMIC  CHANGES  221 

long  before  delivery,  and  from  the  third  month  onward  it  is 
usually  possible  to  squeeze  out  a  drop  of  clear  mucoid  fluid,  which 
in  the  latter  half  of  pregnancy  contains  numerous  colostrum 
corpuscles.  Occasionally,  fluid  may  even  exude  spontaneously 
from  the  nipple  and  from  the  tubercles  of  the  areola,  many  of 
which  are  connected  with  the  lactiferous  ducts. 

The  Face  and  Limbs. — In  addition  to  the  changes  already 
enumerated,  certain  others  are  very  commonly  seen  in  other  parts 
of  the  body.  In  the  early  months,  the  face  often  appears  some- 
what drawn  and  haggard,  and  dark  rings  under  the  eyes  are 
usually  present,  indicative  of  sluggish  circulation.  Later  on, 
symmetrical  pigmented  areas  may  appear  of  a  brownish  colour, 
and  situated  as  a  rule  on  the  forehead,  or  beneath  the  eyes.  The 
latter  patches  often  coalesce  over  the  bridge  of  the  nose.  Some- 
times, no  definite  pigmented  areas  appear,  but  the  whole  face 
assumes  a  slightly  deeper  tint  than  normal.  Increased  pigmenta- 
tion may  also  be  found  in  the  neighbourhood  of  the  axillae.  The 
lower  portion  of  the  neck  often  appears  unusually  full  due  to  hyper- 
trophy of  the  thyroid  gland,  and  pulsation  in  the  gland  may  be 
very  distinct.  Enlargement  of  the  thyroid  also  occurs,  often  to 
a  marked  degree,  at  each  menstrual  period  in  the  non -pregnant 
state,  and  must  be  regarded  as  a  reflex  nervous  phenomenon. 

The  veins  of  the  lower  limbs  usually  manifest  the  increased 
pressure,  which  is  exerted  within  the  abdomen  upon  the  inferior 
vena  cava,  by  becoming  dilated,  and  cedema  about  the  ankles  is 
also  common.  In  the  early  stages  of  pregnancy,  the  smaller 
superficial  veins  below  the  knee  are  most  affected,  and  often 
appear  as  characteristic  bunches  beneath  the  skin.  Later,  the 
larger  veins  also  share  in  the  dilatation,  and  may  become  so  large 
as  to  make  their  rupture  probable. 

Pelvic  Joints.— The  changes  in  the  pelvic  joints  will  be  referred 
to  when  discussing  the  physiology  of  labour. 

Systemic  Changes. — The  functional  and  systemic  changes 
which  occur  during  pregnancy,  for  the  most  part,  tend  to  enable 
the  maternal  organism  to  supply  the  necessary  amount  of  nourish- 
ment and  oxygen  to  the  growing  foetus,  and  to  provide  for  the 
elimination  of  its  waste  products.  The  rapid  cell  proliferation 
and  enlargement,  which  are  taking  place  in  the  reproductive 
organs  of  the  mother  herself  also  necessitate  a  general  increase  in 
body  metabolism. 

Circulatory  System. — The  general  enlargement  of  the  uterine 
bloodvessels,  and  the  complex  arrangement  of  the  uterine  vascular 
system,  render  the  quantity  of  blood  which  is  present  in  the  non- 
pregnant state  quite  inadequate  to  supply  at  a  proper  pressure 
a  sufficient  amount  of  nutritive  fluid  to  the  body  generally  during 
pregnancy.  The  total  quantity  of  blood  is  therefore  increased, 
but  the  increase  consists  more  of  the  watery  than  of  the  solid 
constituents.     The  percentage  amount  of  albumin  in  the  liquor 


222  THE  PHYSIOLOGY  OF  PREGNANCY 

sanguinis  and  the  percentage  number  of  red  blood  corpuscles  are 
diminished,  but  the  number  of  white  blood  corpuscles,  especially 
the  polymorphonuclear  variety,  is  increased,  and  the  coagulation 
time  is  generally  believed  to  be  diminished,  though  this  last 
statement  has  recently  been  denied.  The  haemoglobin  index  is 
also  said  to  be  lowered.  The  extra  work  thrown  upon  the  heart 
by  the  necessity  for  propelling  this  increased  amount  of  fluid 
through  the  enlarged  vascular  system  leads  to  slight  dilatalion 
and  to  hypertrophy  of  the  left  ventricle  of  the  heart.  The 
blood-pressure  is  higher  than  normal,  and  as  a  rule  the  rate  of 
the  pulse  is  increased. 

Respiratory  System. — Owing  to  the  pressure  from  below  upon 
the  diaphragm,  respiration  becomes  almost  entirely  of  a  high 
costal  type  and  is  somewhat  embarrassed,  but  its  rate  is  not 
increased,  since  the  diminution  in  vertical  extent  of  the  thorax  is 
compensated  by  an  increased  breadth  at  the  base.  Dyspnoea, 
however,  readily  occurs  when  the  least  exertion  is  undertaken. 
As  would  be  expected,  the  elimination  of  carbon  dioxide  gas  is 
largely  increased.  During  the  last  month  of  pregnancy,  respira- 
tion again  becomes  easier,  owing  to  the  gradual  subsidence  of  the 
uterus  which  occurs  at  that  date. 

Urinary  System. — During  pregnancy,  the  urine  is  increased  in 
amount,  probably  on  account  of  the  increased  blood-pressure,  and 
becomes  more  watery,  although  the  absolute  amount  of  solids 
excreted  is  really  greater.  A  copper-reducing  substance,  which 
has  proved  on  analysis  to  be  lactose,  is  often  found  in  the  second 
half  of  pregnancy,  and  is  almost  certainly  absorbed  into  the 
circulation  from  the  breasts.  A  deposit  called  kyesteine  is  often 
found  as  a  pellicle  on  the  surface  of  the  urine,  and  was  at  one  time 
regarded  as  characteristic  of  pregnancy.  It  is,  however,  by  no 
means  always  present  in  pregnancy,  and,  moreover,  may  occur  in 
the  urine  of  non-pregnant  females  and  of  males,  being,  in  fact, 
produced  by  fermentation  of  the  urine.  It  does  not  appear  at 
once  after  expulsion,  but  on  about  the  third  day  the  urine  becomes 
cloudy,  and  a  flocculent  sediment  forms,  which  later  sinks  to  the 
bottom  of  the  vessel.  If  examined  microscopically,  it  is  found 
to  be  composed  of  crystals  of  triple  and  other  phosphates,  and  of 
a  large  number  of  bacteria.  Throughout  the  whole  course  of 
pregnancy,  micturition  is  more  frequent  than  normal,  and  is 
especially  marked  while  the  uterus  is  contained  within  the  pelvis. 
At  the  fourth  month,  alleviation  of  this  unpleasant  symptom  may 
occur  coincident  with  the  ascent  of  the  uterus. 

Digestive  System. — The  appetite  is  usually  good,  and  a  very 
large  quantity  of  food  is  taken  and  assimilated  in  order  to  cope 
with  the  demand  for  nourishment.  Morning  sickness,  which  is  so 
often  present  in  the  earlier  months,  must  be  classed  as  a  reflex 
nervous  phenomenon,  dependent  on  the  hypersensitiveness  of 
the  nervous  system.  The  constipation  that  occurs  is  probably 
more  the  result  of  want  of  tone  in  the  wall  of  the  gut  than  of 


SYSTEMIC  CHANGES  223 

direct  pressure  upon  the  intestines.  During  the  whole  period  of 
pregnancy  the  weight  progressively  increases,  but  especially 
during  the  last  three  months,  It  has  been  estimated  that  the 
gain'  equals  about  one-thirteenth  of  the  body-weight,  and  that 
the  average  increase  is  5  lbs.  4  oz.  (2,400  grammes)  during  the 
eighth  month;  3  lbs.  11  oz.  (1,690  grammes)  during  the  ninth 
month;  and  3  lbs.  6  oz.  (1,540  grammes)  during  the  tenth  month 
(Hecker  and  Gassner).  It  is  not  altogether  due  to  the  develop 
ment  of  the  ovum,  for  the  entire  organism  shares  in  the  hyper- 
trophy. Fat  is  deposited  in  many  places,  and  most  abundantly 
around  the  breasts  and  in  the  great  omentum.  Fat  may  also 
be  found  in  the  viscera,  and  sometimes  gives  rise  to  definite 
yellowish  areas  within  the  liver. 

Nervous  System. — That  the  nervous  system  is  functionally 
altered  is  manifested  by  its  heightened  sensibility  and  irritability 
to  nervous  stimuli.  The  whole  organism  is  in  a  state  of  strain, 
and  slight  causes  suffice  to  move  it  either  in  the  direction  of 
abnormal  depression  and  melancholia,  or  in  the  direction  of 
excessive  exhilaration.  The  controlling  power  of  the  will  is 
diminished,  and  hysterical  attacks  may  develop  frequently  in 
those  who  are  already  so  predisposed.  When  the  alteration  is 
confined  within  physiological  limits,  it  leads  merely  to  occasional 
fits  of  depression,  to  peevishness  of  temper,  attacks  of  neuralgia, 
and  slight  morning  sickness.  The  '  longings '  of  pregnancy  are 
due  to  the  same  cause.  Frequently,  however,  the  change  exceeds 
what  may  be  called  normal,  and  a  whole  series  of  pathological 
phenomena,  both  physical  and  mental,  may  then  make  their 
appearance. 

Osseous  System. — Two  changes  are  noticeable  in  the  osseous 
system,  the  first  of  which  is  the  result  of  mechanical  causes,  and 
the  second  the  result  of  metabolic  changes.  Owing  to  upward 
and  forward  development  of  the  uterus,  the  centre  of  gravity  of 
the  body  is  displaced  slightly  forward,  and,  to  counterbalance 
this,  the  shoulders  and  upper  part  of  the  body  move  back- 
wards. This  causes  the  normal  curvature  of  the  lumbar  region 
of  the  spinal  column  to  be  increased,  and  leads  to  an  apparent 
approximation  of  the  shoulders  and  buttocks.  The  obliquity  of 
the  pelvis  is  slightly  diminished. 

In  1838,  Rokitansky"  described  what  he  turned  puerperal 
osteophytes  as  occurring  in  pregnancy.  They  are  a  series  of 
osseous-like  plates  occurring  on  the  inner  table  of  the  cranial 
bones,  between  them  and  the  dura  mater,  and  may  either  remain 
distinct  from  one  another  or  coalesce  to  form  a  continuous  thin 
bony  layer.  They  are  largely  composed  of  carbonate  of  lime,  and 
the  cause  of  their  deposit  is  not  clearly  understood.  They  are  not 
peculiar  to  pregnancy,  being  found  in  some  wasting  diseases.  It 
is  probable  that  in  some  cases  they  remain  permanently. 

*  Rokitansky,  Carl,  '  Manual  of  Pathological  Anatomy '  (trans,  for  Sydenham 
Society,  vol.  iii.,  p.  208). 


CHAPTER  II 
THE  DIAGNOSIS  OF  PREGNANCY 

The  Existence  of  Pregnancy  ;  Subjective  Symptoms  ;  Objective  Symptoms — 
The  Differential  Diagnosis  of  Pregnancy — The  Diagnosis  of  Nulliparity 
or  Parity — The  Age  of  Pregnancy  and  the  Presumed  Date  of  Labour — The 
Situation  of  the  Pregnancy— Single  or  Multiple  Pregnancy — The  Condi- 
tion of  the  Foetus — The  Presence  of  Complications. 

It  is  frequently  of  the  greatest  importance  to  be  able  to  make 
an  early  diagnosis  of  the  existence  of  pregnancy,  as  upon  the 
answer  to  the  question,  Is  the  patient  pregnant  ?  may  depend 
matters  of  the  gravest  importance  both  to  her  and  to  her  medical 
adviser.  It  is  therefore  incumbent  on  all  medical  men  to  make 
themselves  familiar  with,  and  capable  of  recognising,  the  various 
signs  and  symptoms  which  indicate  pregnancy.  It  is  also  neces- 
sary that  they  should  be  familiar  with  the  relative  value  of 
the  different  signs  and  symptoms,  and  not  be  led  into  the  error 
of  attributing  a  positive  value  to  those  which  are  only  useful 
as  supplementary  evidence.  A  medical  man  can  never  too  care- 
fully remember  that  the  evidence  of  pregnancy  must  be  divided 
into  two  groups — negative  evidence  and  positive  evidence,  and 
that  the  opinion  he  gives  to  the  patient  or  her  friends  must  be 
guarded  in  many  cases  unless  it  is  dictated  by  certainty.  The 
unpleasant  results  which  may  follow  in  some  cases  from  a  mistaken 
diagnosis  of  pregnancy  for  the  patient  and  her  friends- — results 
which  are  certain  to  be  reflected  upon  the  medical  adviser — must 
make  us  pay  proper  attention  to  this  point.  It  may  be  possible  to 
state  with  certainty  that  a  patient  is  or  is  not  pregnant,  or  it  may 
not  be  possible  to  give  a  definite  opinion.  Approach  every  case 
without  prejudgment,  and  with  distrust — distrust  of  appearances, 
of  the  statements  of  the  patient  and  her  friends,  and  of  your  own 
powers  of  definite  diagnosis.  Then,  having  made  a  detailed 
examination,  compare  appearances,  statements,  and  the  result  of 
your  examination.  We  have  seen  a  casein  which  a  medical  man, 
the  sister  of  the  patient,  and  the  patient  herself,  all  agreed  in 
stating  that  the  patient  was  pregnant,  the  two  last  adding  the 
information  that  she  was  married  and  at  the  time  of  examination 
actually  in  labour.  The  appearance  of  the  patient  suggested 
a  pregnancy  of  eight  months.     The  examination  of  the  patient 

224 


THE  SUBJECTIVE  SYMPTOMS  OF  PREGNANCY  225 

under  an  anaesthetic  revealed  the  fact  that  pregnancy  if  present 
was  not  intra-uterine,  but  was  possibly  extra-uterine.  It  was 
only  after  the  abdomen  was  opened  that  the  abdominal  enlarge- 
ment was  determined  to  be  due  to  a  iibro-cystic  tumour  of  the 
ovary.  Then,  the  patient  and  her  sister  stated  that  the  former 
was  not  married,  and  that  it  was  quite  impossible  for  her  to  be 
pregnant,  a  fact  which  was  supported  by  clinical  evidence. 

In  order  to  make  a  complete  diagnosis  in  a  case  of  supposed 
pregnancy,  we  must  obtain  information  on  the  following  points  : — 
The  existence  of  pregnancy.  The  age  of  pregnancy  and  the  pre- 
sumed date  of  labour.  The  situation  of  the  pregnancy,  intra-  or 
extra-uterine.  The  number  of  infants.  The  condition  of  the 
foetus.     The  presence  of  complications. 

The  Existence  of  Pregnancy. 

The  various  symptoms  of  pregnancy  are  divided  into  two 
groups  : — Subjective  symptoms,  i.e.,  the  symptoms  of  which  the 
patient  acquaints  us ;  objective  symptoms,  i.e.,  the  symptoms  which 
we  ascertain  for  ourselves  as  the  result  of  an  objective  examination. 

Subjective  Symptoms. — The  subjective  symptoms  of  preg- 
nancy never  possess  more  than  a  negative  value,  inasmuch  as  we 
must  entirely  depend  upon  the  patient  for  their  accuracy.  Conse- 
quently, by  themselves  they  are,  comparatively  speaking,  value- 
less. When,  however,  we  use  them  as  evidence  supplementary 
to  the  objective  symptoms,  and  when  we  find  that  they  agree  with 
the  latter,  their  corroborative  value  is  considerable.  The  following 
are  the  principal  subjective  symptoms  : — 

Suppression  of  the  Menses. — As  a  rule,  the  first  thing  which 
suggests  to  a  patient  that  she  is  pregnant  is  the  suppression  of 
menstruation,  but  it  must  not  be  forgotten  that  suppression  may 
occur  from  many  other  causes.  If  amenorrhoea  occurs  in  a  woman 
in  good  health  who  has  been  menstruating  regularly,  and  if  the 
stated  period  of  amenorrhoea  corresponds  with  the  size  of  the 
uterus  and  with  the  other  results  of  the  physical  examination, 
amenorrhoea  may  be  considered  as  of  diagnostic  value,  otherwise 
its  value  is  small.  Pregnancy  may  be  supposed  to  exist  owing 
to  the  suppression  of  menstruation  from,  for  instance,  anaemia, 
tuberculosis,  ovarian  atrophy,  etc.  On  the  other  hand,  the 
presence  of  pregnancy  may  be  overlooked  owing  to  its  superven- 
tion on  a  previous  period  of  amenorrhoea,  as  during  lactation ; 
or  owing  to  the  association  of  a  periodical  discharge  with  preg- 
nancy, a  possibility  which  is  avowed  by  some  authorities,  and 
which  will  be  discussed  later.  It  must  not  be  forgotten  that,  if 
a  patient  desires  to  deceive  the  medical  attendant,  the  giving  of 
a  false  menstrual  history  is  the  readiest  manner  in  which  she 
can  do  so. 

Quickening.  —  Quickening  is  the    term   applied   to  the   sensa^ 

15 


226  THE  PHYSIOLOGY  OF  PREGNANCY 

tion  which  the  patient  experiences  when  she  detects  the  move- 
ments of  the  foetus  for  the  first  time  in  any  pregnancy.  It  is  an 
old  term  which  originated  in  the  idea  that  its  occurrence  corre- 
sponded with  the  inception  of  life  in  the  foetus.  The  sensation 
which  the  patient  experiences  has  been  compared  to  the  fluttering 
movements  of  a  small  bird  when  held  in  the  hand.  It  is  obvious 
that  such  a  sensation  can  readily  be  simulated  by  other  causes, 
more  especially  by  the  movements  of  flatus  in  the  intestines,  or  that 
the  foetal  movements  may  for  some  time  pass  entirely  unnoticed, 
until  they  assume  more  perceptible  dimensions.  Consequently,  the 
value  of  quickening  as  a  diagnostic  sign  is  very  slight.  It  is  said 
to  occur,  as  a  rule,  about  the  eighteenth  week.  If  a  multiparous 
woman,  who  has  had  previous  experience  of  the  sensation, 
describes  its  occurrence,  some  importance  may  be  attached  to 
her  statements,  more  especially  if  the  date  of  the  occurrence  of 
quickening  corresponds  with  the  menstrual  history  and  the 
physical  signs.  In  the  case  of  a  primipara,  it  is  a  sign  of  no 
value. 

Morning  Sickness.  —  Morning  sickness  is  the  term  applied 
to  the  nausea  and  slight  vomiting  which  are  of  common  occur- 
rence during  the  first  four  months  of  pregnancy  on  wakening  in 
the  morning.  As  a  rule,  it  commences  at  the  beginning  of  the 
second  month  and  continues  to  the  end  of  the  third  month,  but  its 
occurrence  and  duration  are  very  irregular.  If  it  is  met  with  in 
the  case  of  an  otherwise  healthy  woman,  and  if  no  cause  other 
than  pregnancy  can  be  found  for  it,  it  constitutes  a  symptom  of  a 
slight  corroborative  value.  Its  causes  will  be  discussed  in  another 
place. 

The  foregoing  are  the  most  important  subjective  symptoms  of 
pregnancy,  and  are  met  with  in  the  great  proportion  of,  or  in  all, 
cases  of  pregnancy.  There  are,  however,  certain  conditions  which 
occur  as  tolerably  regular  phenomena  in  some  women,  so  much  so 
that  such  patients  may  base  the  knowledge  that  they  are  preg- 
nant upon  them.  The  most  important  of  these  are  the  occurrence 
of  salivation,  of  various  neuralgic  affections,  of  temporary  altera- 
tions in  the  temperament  and  the  appetite.  So  well  is  the  occur- 
rence of  the  last  of  these  recognised  that  the  term  '  longings,'  or 
pica,  has.  been  applied  to  the  various  fancies  or  even  cravings  by 
which  a  pregnant  woman  may  sometimes  become  possessed,  and 
which  are,  perhaps,  at  complete  variance  with  her  ordinary  in- 
clinations. The  older  works  on  obstetrics  are  full  of  references 
to  such  fancies,  and  mention  of  them  also  occurs  in  general 
literature.*  The  diagnostic  value  of  these  phenomena  is  nil,  save 
possibly  to  the  patient  herself. 

*   '  She  can  cranch 

A  sack  of  small  coal,  eat  you  lime  and  hair, 
Soap,  ashes,  loam,  and  has  a  dainty  spice 
Of  the  green  sickness.' 

Ben  Jonson  :  TJie  Magnetic  Lady,  Act  i.,  Scene  i. 


THE  OBJECTIVE  SYMPTOMS  OF  PREGNANCY  227 

Objective  Symptoms. — In  order  to  ascertain  the  presence  of 
the  objective  symptoms  of  pregnancy,  a  careful  and  systematic 
examination  of  the  patient  must  be  made.  We  have  already 
described  the  methods  by  which  such  an  examination  must  be 
conducted,  and  the  nature  and  cause  of  the  changes  met  with, 
and  here  we  shall  merely  enumerate  the  latter  and  discuss  their 
diagnostic  value. 

The  Face.  — ■  The  only  alteration  of  importance  which  is 
noticeable  on  the  face  is  the  increase  in  pigmentary  deposit. 
This  occurs  especially  at  the  sides  of  the  nose,  under  the  eyes, 
and  in  the  region  of  the  upper  lip.     Its  diagnostic  value  is  slight. 

The  Breasts. — The  relation  between  the  breasts  and  the 
generative  organs  is  so  close  that  naturally  early  indications  of 
pregnancy  are  to  be  found  in  the  former.  The  various  changes 
which  occur  have  been  already  described  ;  in  their  order  of  relative 
importance  they  are  as  follows  : — 

(1)  Enlargement  and  Increased  Firmness  of  the  Breast. — A  slight 
degree  of  fulness  of  the  breasts  may  be  appreciated  by  the 
patient  herself  within  a  few  weeks  after  conception,  but  it  is  not 
until  the  completion  of  the  second  month  that  any  enlargement  is 
noticeable  to  the  physician.  From  that  time  on,  the  breasts 
become  progressively  larger,  firmer,  and  more  knotty.  Both  these 
alterations  are  very  constant  in  pregnancy,  but  they  may  also 
result  from  other  causes,  and  may  be  found  in  association  with 
myomata  of  the  uterus  and  ovarian  tumours.  Accompanying 
the  enlargement  of  the  breast  itself  is  an  enlargement  of  the 
superficial  veins,  causing  the  appearance  of  a  delicate  marbling 
of  the  skin.  This  change  is,  perhaps,  more  confined  to  preg- 
nancy than  is  the  enlargement  of  the  breast  tissue,  inasmuch  as  it 
is  evidence  of  an  acuter  process  of  hypertrophy  than  would  occur 
in  the  case  of  an  ovarian  or  uterine  tumour. 

(2)  The  Presence  of  Fluid. — The  presence  of  a  little  fluid  in  the 
breast  can  usually  be  determined  from  the  third  month  onwards, 
if  the  breast  is  gently  squeezed  in  the  direction  of  the  nipple. 
Such  fluid  is  usually  clear,  and,  though  its  presence  is  almost 
invariably  associated  with  pregnancy,  it  affords  no  positive  evi- 
dence of  its  existence,  as  it  is  very  frequently  met  with  in  cases 
of  uterine  enlargement  from  other  causes,  and  of  ovarian  tumours. 
It  can  also  be  frequently  found  in  the  breast  of  a  multipara,  even 
when  not  pregnant,  in  which  case  it  is  probably  the  remains  of 
a  previous  lactation.  Later  in  pregnancy,  an  opaque  fluid  can 
usually  be  expressed  from  the  breast,  containing  colostrum  cor- 
puscles. It  is  said  that  the  presence  of  these  corpuscles  is  an 
almost,  if  not  absolutely,  certain  sign  of  pregnancy  (Galabin). 

(3)  Alterations  in  the  Nipples  and  the  Primary  Areola. — The  most 
important  of  these  alterations  consist  in  a  turgescence  of  the 
nipple  and  of  the  skin  round  it,  in  a  deepening  of  the  colour  of  the 
primary  areola,  and  in  the  presence  of  Montgomery's  follicles  on 
the   areola.       The   turgescence    of    the    nipple    is    said    to    be 

J5— 2 


228  THE  PHYSIOLOGY  OF  PREGNANCY 

found  from  the  end  of  the  second  month  onwards,  while  the 
other  changes  take  place  during  the  following  two  or  three 
months.  Turgescence  is  very  characteristic  of  pregnancy,  but 
may  also  occur  in  connection  with  the  other  causes  of  uterine 
irritation. 

(4)  The  Secondary  Areola.— The  presence  of  this  can  be  deter- 
mined from  the  fifth  month  onwards.  It  was  said  by  Montgomery, 
who  described  it,  to  '  exclusively  result  from  pregnancy.'  It  is, 
however,  difficult  to  say  definitely  that  it  may  not  and  does  not 
result  from  other  causes,  and  consequently  it  is  not  advisable  to 
include  it  among  the  certain  signs  of  pregnancy.  Moreover,  at 
the  time  at  which  the  secondary  areola  appears,  it  is  usually 
possible  to  obtain  more  positive  proof. 

The  diagnostic  value  of  the  foregoing  signs  depends  largely 
upon  the  fact  that  their  existence  can  be  determined  without 
arousing  the  suspicions  of  the  patients  as  to  the  reason  for  our 
examination.  This  is  particularly  the  case  in  girls  suffering  from 
amenorrhcea,  the  cause  of  which  is  uncertain.  In  such  cases, 
under  the  pretext  of  examining  the  heart,  we  can  frequently 
detect  mammary  signs,  which,  though  not  sufficient  to  base  a 
definite  diagnosis  upon,  are  yet  still  sufficiently  suggestive  to 
enable  us  to  form  a  fairly  reliable  private  opinion  of  the  nature 
of  the  case. 

The  Abdomen.  —  As  the  abdominal  signs  of  pregnancy 
possess  the  greatest  diagnostic  value,  it  will  be  well  to  enumerate 
them  under  different  headings,  according  to  the  method  of 
examination  by  which  they  are  elicited. 

Inspection.  —  The  following  changes  which  take  place  in  the 
abdomen  during  pregnancy  can  be  determined  by  inspection  : — 

(1)  Change  of  Shape. — -During  the  first  two  months,  the  abdomen 
between  the  symphysis  and  the  umbilicus  is  flatter  than  usual, 
probably  owing  to  the  sinking  of  the  uterus  into  the  pelvic  cavity 
and  the  consequent  additional  room  afforded  for  the  viscera.  It  is 
quite  a  contrary  change  to  what  would  be  expected,  but  has  been 
regarded  as  a  sign  of  pregnancy  for  a  very  long  time,  as  various 
old  proverbs  show.*  From  the  middle  of  the  fourth  month 
onwards,  the  abdomen  enlarges  symmetrically  and  progressively 
up  to  the  end  of  the  ninth  month.  Then,  during  the  tenth  month, 
the  fundus  falls  to  the  level  it  occupied  at  the  end  of  the  eighth 
month. 

(2)  Increase  of  Pigmentary  Deposit.  — There  is  very  commonly 
a  well-marked  brown  line  running  from  the  umbilicus  to  the 
symphysis,  and  increased  pigmentation  in  the  neighbourhood  of 
the  groin. 

(3)  Occurrence  of  striae,  or  lineae  gravidarum. 

(4)  The  Movements  of  the  Foetus. — These  may  be  seen  during 

*  '  En  ventre  plat  '  In  a  belly  that's  flat 

Un  enfant  il  y  a. '  There's  a  child — be  sure  of  that.' 


THE  OBJECTIVE  SYMPTOMS   OF  PREGNANCY  229 

the  last  three  months  of  pregnancy,  or  even  earlier  in  the  case  of 
a  strong  foetus  and  a  thin  abdominal  wall. 

The  results  of  inspection  are,  with  the  exception  of  the  last,  of 
no  great  value  from  a  diagnostic  point  of  view. 

Percussion.  —  By  means  of  percussion  of  the  abdomen  the 
existence  of  a  tumour,  dull  on  percussion  and  medianly  situated, 
can  be  determined,  and  its  contour  mapped  out. 

Palpation. — The  following  signs  can  be  detected  by  means  of 
abdominal  palpation  :  — 

(1)  The  Presence  of  a  Tumour  in  the  Abdomen. — After  the  fourth 
month  a  tumour  can  be  felt  rising  out  of  the  pelvis  and  extending 
into  the  abdomen  to  a  degree  proportionate  to  the  period  of 
pregnancy.  It  is  medianly  situated,  smooth,  and  uniform  in 
outline,  with  fluid  contents,  in  which,  after  the  fourth  month,  the 
foetus  can  be  felt. 

(2)  The  Foetal  Parts  and  Movements. — -The  foetal  parts  can  be 
felt  by  external  ballottement,  in  a  favourable  case,  as  soon  as  the 
uterus  has  risen  sufficiently  far  above  the  pelvic  brim  to  enable 
this  manipulation  to  be  performed.  Up  to  the  end  of  the  fifth 
month,  the  entire  foetus  can  be  moved  in  this  way  inside  the 
uterus ;  but,  after  the  fifth  month,  the  foetus  has  reached  too  large 
a  size  in  comparison  with  the  size  of  the  uterine  cavity  to  allow 
this,  and  consequently  only  a  portion  of  it — a  limb  or  the  head — 
can  be  ballotted.  As  the  sensation  of  ballottement  can  only  be 
conveyed  by  a  solid  body  floating  in  fluid,  there  are  very  few 
conditions  save  pregnancy  which  can  furnish  it.  External 
ballottement  can  in  all  probability  only  be  simulated  by  a  sub- 
peritoneal pedunculated  myoma,  or  by  cancerous  masses,  floating 
in  ascitic  fluid,  or  by  the  extremely  improbable  association  of  an 
intra-uterine  polypus  and  haematometra  or  pyometra.  In  the 
former  cases,  the  fact  that  the  outline  of  the  uterus  cannot  be 
felt  will  usually  enable  us  to  exclude  pregnancy  ;  in  the  latter 
case,  the  attendant  symptoms  and  the  results  of  a  further  examina- 
tion will  be  sufficient  to  make  the  condition  present  obvious. 
During  the  last  four  months  of  pregnancy,  the  foetal  parts  can,  in 
addition,  be  palpated  and  recognised.  The  active  movements  of 
the  foetus  can  be  readily  felt  by  laying  the  hand  on  the  abdomen 
over  a  limb  and  keeping  it  there  for  a  moment.  If  the  foetus  is 
pushed  slightly  with  the  other  hand,  it  will  usually  respond  with 
a  movement,  or  if  the  patient  takes  a  deep  breath  the  same  result 
is  said  to  follow  (Jacquemin). 

(3)  The  Contractions  of  the  Uterus. — The  occurrence  of  painless 
and  intermittent  contractions  of  the  uterus  which  are  perceptible 
from  the  third  month  of  pregnancy  onwards  was  first  determined 
by  Braxton  Hicks, :;:  by  whom  its  value  as  a  symptom  of  preg- 
nancy was  also  demonstrated.  It  is  consequently  known  as 
Braxton   Hicks'  sign.     In  the   later  months  of  pregnancy  it  is 

*  '  Selected   Essays  and  Monographs  from   English  Sources,'  New  Syden- 
ham Society,  vol.  clxxiii.,  p.  25. 


230  THE  PHYSIOLOGY  OF  PREGNANCY 

easy  to  determine  its  presence  by  laying  one  hand  flat  on  the 
abdomen,  but  in  the  earlier  months  it  is  more  difficult.  Braxton 
Hicks'  directions  for  obtaining  it  are  as  follows  :  '  If,  then,  the 
uterus  be  examined  without  friction  or  any  pressure  beyond  that 
necessary  for  full  contact  of  the  hand  continuously  over  a  period 
of  from  five  to  twenty  minutes,  it  will  be  noticed  to  become  firm 
if  relaxed  at  first,  and  more  or  less  flaccid  if  it  be  firm  at  first. 
It  is  seldom  that  so  long  an  interval  occurs  as  that  of  twenty 
minutes ;  most  frequently  it  occurs  every  five  or  ten  minutes, 
sometimes  even  twice  in  five  minutes.'  Braxton  Hicks  admits 
that  this  sign  may  also  occur  in  some  myomatous  tumours,  but 
thinks  that  in  such  cases  it  is  not  difficult  to  make  a  differential 
diagnosis. 

The  information  afforded  by  abdominal  palpation  is  most  im- 
portant, particularly  in  the  later  months  of  pregnancy.  The 
recognition  of  the  foetal  parts  and  the  detection  of  the  foetal 
movements  are  certain  signs  of  pregnancy.  External  ballotte- 
ment  is  an  almost,  but  not  absolutely,  certain  sign,  while  Braxton 
Hicks's  sign  is  of  great  value  as  a  corroborative  sign. 

Auscultation. — The  various  signs  which  can  be  detected  by 
auscultation  are  as  follows  : — 

(i)  The  Foetal  Heart. —  This  can  be  detected  from  the  sixteenth 
to  the  eighteenth  week  onward.  It  can  only  be  confused  with 
the  maternal  heart  or  the  pulsations  of  the  listener's  heart.  In 
either  case,  the  error  can  readily  be  avoided  by  comparing  their 
respective  rates  with  that  of  the  presumed  foetal  heart. 

(2)  The  Funic  or  Umbilical  Souffle.- — This  is  only  heard  under 
certain  conditions  to  which  reference  has  been  already  made.  It 
can  be  confused  with  the  uterine  souffle,  or  a  cardiac  bruit  trans- 
mitted from  the  maternal  heart. 

(3)  The  Uterine  Souffle. — This  can  be  heard  in  practically  every 
case,  and  may  be  detected  as  early  as  the  fifteenth  or  sixteenth 
week — a  time  at  which  it  is  rarely,  if  ever,  possible  to  detect  the 
foetal  heart.  It  may,  however,  be  also  heard  in  uterine  enlarge- 
ments from  other  causes  than  pregnancy. 

(4)  The  Movements  of  the  Foetus. — It  is  sometimes  possible  to 
detect  the  foetal  movements  by  auscultation.  As,  however,  it  is 
difficult  to  do  so,  as  they  can  be  confused  with  intestinal  sounds, 
and  as  at  the  time  when  they  can  be  heard  it  is  possible  to 
ascertain  the  existence  of  a  foetus  by  other  means,  the  diagnostic 
value  of  this  procedure  is  small. 

The  auscultatory  signs  of  pregnancy  possess  a  high  diagnostic 
value.  The  foetal  heart  and  the  funic  souffle  are  the  earliest 
certain  signs  of  pregnancy  ;  the  uterine  souffle  is  a  probable  sign, 
and  is  of  value  when  found  in  conjunction  with  other  signs. 

The  Vulva  and  Vagina. — The  information  afforded  by  examina- 
tion of  the  vagina  and  vulva  is  of  extreme  importance  in  the 
diagnosis  of  pregnancy.  The  various  signs  which  are  thus 
determined  are  as  follows  : — 


THE  OBJECTIVE  SYMPTOMS  OF  PREGNANCY  231 

(1)  Alteration  in  Colour  of  the  Vulvar  and  Vaginal  Mucous  Mem- 
brane.— Attention  was  first  called  to  the  importance  of  this  change 
as  a  sign  of  pregnancy  by  Jacquemin,  of  Paris,  who  said  that  in 
cases  of  pregnancy  the  vulvar  and  vaginal  mucous  membrane 
became  of  a  violet  colour,  like  the  lees  of  port  wine.  The  altered 
colour  is,  however,  perhaps  better  described  by  Montgomery  as 
being  of  a  livid  or  dusky  hue."  It  can,  as  a  rule,  be  detected  during 
the  second  month,  and  increases  in  intensity  during  the  next  three 
months,  at  the  end  of  which  it  has,  perhaps,  attained  its  maximum. 
It  persists  throughout  pregnancy.  In  the  vulva,  it  is  most  distinct 
on  the  inside  of  the  labia  minora,  and  round  the  urethra.  In  the 
vagina,  it  increases  in  intensity  from  below  upwards,  and  is  most 
marked  in  the  fornices.  Its  intensity  varies  considerably  in 
different  subjects.  As  it  is  purely  mechanical  in  origin,  and  is 
dependent  on  venous  stasis  due  to  the  pressure  of  the  enlarged 
uterus  on  veins  already  engorged  with  blood,  it  can  occur  in 
conditions  other  than  pregnancy.  Thus,  it  may  be  met  with 
during  menstruation  and  in  certain  cases  of  uterine  myomata. 
It  is,  however,  undoubtedly  better  marked  in  pregnancy  than  in 
either  of  these  conditions,  and  consequently  possesses  a  definite 
diagnostic  value. 

(2)  Alteration  in  the  Size,  Shape,  and  Consistency  of  the  Uterus. — 
The  first  point  which  will  attract  the  attention  of  the  obstetrician 
on  making  a  bi-manual  examination  of  the  uterus  is  the  enlarge- 
ment in  the  size  of  that  organ.  The  size  of  the  uterus  at  the 
different  months  has  been  already  mentioned,  and  need  not  be 
again  referred  to.  It  is  only  necessary  to  call  attention  to  the 
fact  that  in  the  early  months  one  may  be  misled  by  the  soft  and 
flaccid  condition  of  the  uterus,  and  may  overlook  this  enlarge- 
ment. If  a  careful  bi-manual  examination  is  made  this  will  not 
be  the  case. 

In  shape,  the  uterus  becomes  more  globular  during  the  first 
three  months,  in  consequence  of  an  increase  in  its  antero-posterior 
diameters. 

The  alteration,  which  takes  place  in  the  consistency  of  the 
uterus,  is  one  of  the  most  important  early  signs  of  pregnancy. 
It  must  be  considered  from  three  points  of  view  : — Its  effect  on 
the  uterus  as  a  whole ;  its  effect  upon  the  cervix  ;  its  effect  upon 
the  lower  uterine  segment. 

The  entire  uterus  becomes  softer  in  consistency  than  it  is  in  an 
unimpregnated  condition,  and  more  elastic— changes  due  to  the 
increased  blood-supply.  This  softening,  however,  particularly 
affects  two  portions  of  the  uterus— the  cervix  and  the  junction 
of  the  body  and  the  cervix.  The  softening  of  the  cervix  proceeds 
progressively  from  below  upwards,  and  can  be  noticed  from  the 
second  month  onwards.  At  first,  it  affects  the  cervical  mucous 
membrane  alone,  but,  gradually,  the  deeper  tissues  are  involved, 
and,  finally,  the  entire  cervix  is  so  softened  that  to  the  examining 
*  '  Signs  and  Symptoms  of  Pregnancy,'  2nd  edition,  p.  243. 


232  THE  PHYSIOLOGY  OF  PREGNANCY 

finger  it  conveys  as  little  sensation  as  if  it  was  non-existent.  The 
softening  of  the  lower  uterine  segment  just  above  the  insertion  of 
the  utero-sacral  ligaments  was  first  described  as  a  sign  of  preg- 
nancy by  Hegar.*  We  have  already  described  how  it  can  be 
detected.  It  is  very  characteristic,  it  can  be  obtained  from  the 
second  month  onwards,  and  so  it  is  one  of  the  most  reliable,  or 
perhaps  the  most  reliable,  of  the  early  signs  of  pregnancy. 

(3)  Internal  Ballottement. — Internal  ballottement  of  the  foetus  can 
be  obtained  from  the  time  the  foetus  is  sufficiently  large  to  be 
perceptible  until  it  becomes  too  large  to  be  freely  movable  inside 
the  uterus— that  is,  from  the  commencement  of  the  fourth  to  the 
end  of  the  fifth  month.  After  the  latter  month,  the  foetus  can  be 
displaced  by  the  upward  pressure  of  the  fingers,  but  it  will  not 
fall  back  again  on  to  the  finger.  Internal  ballottement  can  un- 
doubtedly be  best  obtained  when  the  patient  is  in  the  erect 
position,  but,  as  it  is  not  usually  possible  to  make  a  vaginal 
examination  in  this  manner,  ballottement  must  be  obtained  while 
she  is  in  the  dorsal  position.  If  a  few  possible  sources  of  error 
are  excluded,  internal  ballottement  is  an  almost  certain  sign  of 
pregnancy.  It  can,  however,  also  be  obtained  in  the  case  of  a 
pedunculated  myoma  or  malignant  masses  floating  in  ascitic  fluid, 
or  inside  a  uterus  in  which  there  is  an  accumulation  of  blood  or 
other  fluid,  or  in  the  case  of  a  large  calculus  lying  in  a  distended 
bladder. 

(4)  Hypertrophy  of  the  Ureters.  —  The  increase  which  occurs 
during  pregnancy  in  the  size  of  the  ureters  can  be  detected  by 
anyone  who  has  made  himself  familiar  with  the  size  of  the  non- 
hypertrophied  ureter  as  felt  from  the  vagina.  To  palpate  the 
ureter,  pass  the  index  finger  into  the  vagina  until  the  anterior 
fornix  is  reached,  and  lay  the  tip  on  the  upper  margin  of  the 
symphysis  with  the  palmar  surface  forwards.  Then,  draw  the 
finger  gently  downwards  and  outwards  along  the  posterior  surface 
of  the  pubes,  and  the  ureter  will  be  felt  as  a  cord  which  runs  at 
right  angles  to  the  direction  in  which  the  finger  is  moving,  and 
which  slips  away  from  beneath  the  latter. 

(5)  Increased  Pulsation  in  the  Lateral  Fornices. — This  will  be  found 
in  any  condition  in  which  the  blood-supply  to  the  uterus  is  in- 
creased, and,  consequently,  does  not  possess  any  very  great 
diagnostic  importance. 

The  information  afforded  by  vaginal  examination  is  of  great 
diagnostic  value,  particularly  in  the  early  months  of  pregnancy, 
when  the  information  which  can  be  subsequently  obtained  by 
examination  of  the  abdomen  is  not  available.  It  is  true  that  no 
certain  sign  of  pregnancy  can  be  elicited  in  this  manner ;  but  two 
probable  signs  can  be  obtained,  which,  if  found  in  conjunction, 
almost  certainly  point  to  the  existence  of  pregnancy.  These 
signs  are, — Hegar's  sign  and  internal  ballottement. 

It  will  perhaps  be  found  of  service  if  we  tabulate  the  foregoing 
*  P yager  Med.  Wochenschr.,  1884,  No.  26. 


THE  DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY 


233 


signs  of  pregnancy  according  to  their  importance,  and  if,  at  the 
same  time,  we  mention  the  period  at  which  they  can  usually  be 
obtained.  We  shall  group  them  in  three  classes  : — the  certain 
signs,  which  can  only  occur  as  a  result  of  pregnancy  ;  the  prob- 
able signs,  which  are  most  frequently  associated  with  pregnancy, 
but  which  may  be  more  rarely  met  with  under  other  cir- 
cumstances ;  and  the  possible  signs,  which  are  present  during 
pregnancy,  but  which  are  frequently  also  met  with  under  other 
circumstances. 


Nature  of  Sign. 

Time  at  which  Detectable. 

Value. 

The  fcetal  heart 

Eighteenth     week     on- 

wards 

Certain  sign. 

The  foetal  parts 

Last  four  months  - 

, , 

Movements     of     fcetus, 

when    felt,    heard,    or 

seen  by  medical  man  - 

Last  three  months 

, , 

Funic  souffle  - 

Occasionally  heard 
during    last     two    or 

three  months 

" 

Breast  changes 

Second  month  onwards 

Probable  sign. 

Vaginal  discoloration 

>i                                 11 

,, 

Hegar's  sign  - 

II                        II 

,, 

Hypertrophy  of  ureters  - 

II                        II 

,, 

Enlargement  of  uterus    - 

II                            II 

, , 

Internal  ballottement 

Fourth  and  fifth  months 

,, 

Uterine  souffle 

Fifteenth  week  onwards 

, , 

Intermittent  contractions 

Fourth  month  onwards 

,, 

External  ballottement     - 

Fifth  month  onwards    - 

" 

Subjective  symptoms 

Second  month  onwards 

Possible  sign. 

Pigmentation  of  face  and 

abdomen 

Fourth  month  onwards 

,, 

Enlargement  of  abdomen 

" 

" 

The  Differential  Diagnosis  of  Pregnancy. 

From  the  foregoing  account  of  the  diagnostic  signs  of  preg- 
nancy, it  will  be  readily  understood  that  even  in  straightforward 
cases  of  uncomplicated  pregnancy  a  certain,  or  even  a  probable, 
diagnosis  is  impossible  during  the  first  month.  From  the  second 
to  the  middle  of  the  fourth  month,  certainty  is  equally  impossible, 
but  it  is  usually  easy  to  make  a  probable  diagnosis.  While,  from 
the  end  of  the  fifth  month  onwards,  a  certain  diagnosis  can  be 
readily  made.  If,  however,  the  nature  of  the  case  is  obscured  by 
the  co-existence  of  pathological  conditions,  then  the  difficulty  of 
making  a  diagnosis  may  be  great,  even  during  the  tenth  month. 
Here,  we  propose  to  discuss  the  differential  diagnosis  of  pregnancy, 
and  the  best  method  in  which  to  do  so  will  be  to  enumerate  the 


234  THE  PHYSIOLOGY  OF  PREGNANCY 

various  pathological  conditions  which  may  tend  to  simulate  a 
non-existent  pregnancy  or  to  obscure  an  existing  one,  and  to 
compare  their  symptoms  and  signs  with  those  of  pregnancy. 

The  following  conditions  may  be  confounded  with  pregnancy  : — 

Amenorrhea  from  Causes  other  than  Pregnancy.  —  The 
presence  of  regular  and  normal  menstruation  is  a  definite  sign 
that  the  patient  is  not  pregnant ;  but  the  mere  fact  that  men- 
struation is  absent,  unless  supported  by  other  evidences,  is  of 
slight  diagnostic  value.  Amenorrhcea  very  commonly  occurs  in 
young  girls  from  sixteen  to  twenty  owing  to  ill-health,  and  in 
cases  in  which  it  is  accompanied  by  an  increased  deposit  of  fat  in 
the  abdominal  walls  the  condition  is  at  first  sight  very  suggestive 
of  pregnancy.  It  is  in  these  cases  that  the  early  information 
afforded  by  the  examination  of  the  breasts,  and  the  possibility  of 
obtaining  this  information  without  exciting  the  suspicions  of  the 
patient,  are  so  important. 

Enlargement  of  the  Uterus.  —  Enlargement  of  the  uterus 
from  causes  other  than  pregnancy,  and  of  such  a  kind  that  it  can 
be  confused  with  pregnancy,  is  by  no  means  an  uncommon  con- 
dition.    It  may  result  from  the  following  conditions  : — 

(i)  Chronic  Metritis  and  Endometritis. — In  enlargement  from  this 
cause,  the  uterus  is  more  firm  in  consistency  than  is  the  case  in 
pregnancy,  and  the  globular  shape  of  the  body  and  the  softening 
of  the  lower  uterine  segment  are  absent.  As  a  rule,  the  cervix 
is  also  more  firm  than  in  pregnancy  ;  but  in  some  cases,  where 
endometritis  is  associated  with  erosion  or  ectropion  of  the  cervical 
mucous  membrane,  or  where  there  is  considerable  congestion  of 
the  uterus,  softening  of  the  cervix  may  also  occur.  In  metritis, 
associated  with  sub-inyolution,  the  diagnosis  may  be  particularly 
difficult ;  but,  as  a  rule,  the  history  of  the  case  will  enable  the 
cause  of  the  enlargement  to  be  determined. 

(2)  Tumours  of  the  Body. — Uterine  enlargement  caused  by  small 
fibro-myomatous  tumours,  or  by  malignant  disease  of  the  body, 
may  sometimes  be  of  such  a  kind  as  to  resemble  pregnancy.  In 
the  former  case,  especially  when  the  tumour  is  interstitial  or  sub- 
mucous, there  may  be  considerable  difficulty  in  diagnosis,  as  the 
uterine  enlargement  of  the  uterus  is  then  often  uniform,  and  all 
the  signs  of  pregnancy  which  are  dependent  on  uterine  conges- 
tion may  be  well  marked.  The  history,  especially  the  menstrual 
history  is,  however,  usually  at  variance  with  the  suggestion  of 
pregnancy  ;  while  in  a  case  of  doubt  time  will  clear  up  the  nature 
of  the  case. 

Uterine  enlargement  caused  by  large  myomata  is  usually  not 
very  difficult  to  distinguish  from  pregnancy.  The  enlargement 
is,  as  a  rule,  irregular,  the  consistency  of  the  uterus  is  firmer,  and 
the  fcetal  parts  cannot  be  felt  nor  the  foetal  heart  be  heard.  On 
the  other  hand,  in  some  cases  the  enlargement  may  be  uniform, 
or  the  irregularities  may  be  of  such  a  shape  as  to  counterfeit 
fcetal  parts.     Real  difficulty  in  diagnosis  is,  however,  rarely  met 


THE  DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY  235 

with,  save  in  complicated  cases  in  which  a  pregnancy  and  a 
myoma,  a  myoma  and  an  ovarian  tumour,  or  a  myoma  and  ascites 
co-exist.  In  such  cases,  the  diagnosis  may  be  most  difficult,  but 
can  usually  be  made  by  comparing  the  results  of  a  careful 
examination  under  an  anaesthetic  with  the  history  of  the  case. 

(3)  Hatmatometra. — The  retention  of  the  menstrual  fluid  in  the 
uterus,  as  a  result  of  atresia  of  the  upper  part  of  the  vagina  or  the 
cervix,  may  simulate  pregnancy,  as  it  will  cause  a  cystic  enlarge- 
ment of  the  uterus  associated  with  amenorrhcea.  The  history  of 
the  case  will,  however,  usually  enable  a  diagnosis  to  be  made,  as 
the  duration  of  amenorrhoea  in  association  with  the  size  of  the 
uterus,  the  spasmodic  increase  in  size  of  the  latter — occurring 
during  what  ought  to  be  a  menstrual  period,  and  the  pain  with 
which  this  increase  is  attended,  are  opposed  to  the  probability  of 
pregnancy.  If  the  history  is  not  sufficient,  a  vaginal  examination 
will  reveal  the  presence  of  an  atresia. 

Ovarian  Tumours. — Small  ovarian  tumours  may  be  mistaken 
for  an  extra-uterine  pregnancy.  The  diagnosis  between  them 
will  be  subsequently  referred  to.  Larger  tumours  may  be  mis- 
taken for  a  pregnant  uterus,  but,  usually,  save  in  the  presence  of 
complications,  the  diagnosis  is  easy.  The  growth  of  an  ovarian 
tumour  is,  as  a  rule,  slower  than  that  of  a  pregnant  uterus, 
menstruation  is  usually  not  suppressed,  and  in  most  cases  it  is 
possible  to  determine  the  presence  of  the  uterus  beside  the  tumour. 
If,  however,  the  case  is  complicated  by  ascites,  or  by  a  co-existent 
pregnancy,  it  may  be  most  difficult  to  make  an  exact  diagnosis. 
In  the  former  case,  it  will  be  well  to  tap  the  abdomen  and  draw 
off  the  ascitic  fluid  if  a  diagnosis  cannot  be  otherwise  made. 

Other  Causes  of  Abdominal  Enlargement. — Other  causes  of 
abdominal  enlargement  which  may  give  rise  to  a  suspicion  of 
pregnancy  are  as  follows  : — ■ 

(1)  An  Overfull  Bladder. — A  bladder,  which  has  become  con- 
siderably overdistended,  may  sometimes  be  found  as  an  ovoid 
fluctuating  tumour  reaching  to  the  umbilicus,  and  perhaps  con- 
tracting intermittently.  It  sometimes  occurs  during  pregnancy, 
especially  in  association  with  the  condition  known  as  incarcera- 
tion of  the  retro-deviated  pregnant  uterus.  It  may  also  occur 
independently  of  pregnancy,  as  a  result  of  compression  of  the 
neck  of  the  bladder.  A  diagnosis  is  not  difficult,  as  it  will  be 
impossible  to  obtain  internal  or  external  ballottement  or  to  hear 
the  foetal  heart,  while  the  passage  of  a  catheter  causes  the  enlarge- 
ment to  disappear.  These  cases  are,  however,  calculated  to  cause 
errors  in  diagnosis  if  the  possibility  of  the  presence  of  a  distended 
bladder  is  overlooked. 

(2)  Accumulation  of  Fat  in  the  Abdominal  Wall  or  Omentum. — This 
condition  will  only  give  rise  to  confusion  in  diagnosis  in  cases  in 
which  it  is  associated  with  amenorrhcea,  as  has  been  already 
mentioned,  and  perhaps  in  patients  near  or  past  the  climacteric,  in 
whom  menstruation  has  ceased. 


236  THE  PHYSIOLOGY  OF  PREGNANCY 

(3)  Phantom  Pregnancy,  or  Pseudo-Cyesis.  —  It  has  sometimes 
happened  that  patients  have  for  purposes  of  fraud  deliberately 
endeavoured  to  feign  a  condition  of  pregnancy,  or  that  they  have 
actually,  and  with  perfect  bond  fides,  persuaded  themselves  that 
they  are  pregnant,  and  that  they  have  succeeded  in  convincing 
their  medical  advisers  that  such  is  the  case.  In  some  of  these 
cases,  the  patients  succeed  in  creating  not  alone  the  appearance, 
but  even  the  sensation  on  palpation,  of  the  presence  of  a  tumour. 
In  cases  of  fraud,  this  '  tumour  '  may  be  created  by  allowing  the 
bladder  to  become  overdistended,  while  in  the  other  class  of 
cases  the  '  tumour  '  is  probably  due  to  a  deposit  of  fat  in  the 
abdominal  walls  or  omentum,  or  to  flatulence  associated  with 
contraction  of  the  abdominal  muscles.  If  the  patient  is  carefully 
examined,  there  is  no  difficulty  in  making  a  diagnosis.  On  per- 
cussion the  abdomen  is  resonant,  and,  if  an  anaesthetic  is  adminis- 
tered, the  rigidity  of  the  muscles  and  the  supposed  tumour 
disappear. 

(4)  Ascites. — A  collection  of  fluid  in  the  peritoneal  cavity  will 
not  give  rise  to  any  difficulty  of  diagnosis  unless  it  is  encysted 
beneath  the  abdominal  wall  in  the  position  which  a  pregnant 
uterus  would  occupy,  or  is  complicated  by  pregnancy  or  by  the 
presence  of  a  tumour  of  the  uterus  or  ovary.  In  such  cases,  the 
diagnosis  may  be  extremely  difficult,  but  it  can  usually  be  made 
from  the  history  of  the  case  and  the  results  of  a  careful  examina- 
tion under  an  anaesthetic.  In  the  case  of  ascites  complicating  an 
abdominal  enlargement,  it  may  be  necessary  to  tap  the  abdomen 
and  draw  off  the  fluid,  in  order  to  ascertain  the  exact  nature  of 
the  case. 

The  Diagnosis  of  Nulliparity  or  Parity. 

It  is  sometimes  a  matter  of  medico-legal  importance  to  be  able 
to  determine  whether  a  patient  has  been  previously  pregnant  or 
not.  It  may  be  stated  that,  as  a  general  rule,  it  is  impossible  to 
tell  whether  a  patient  has  or  has  not  had  a  previous  abortion  ; 
but,  if  delivery  has  occurred  during  the  last  four  months  of  preg- 
nancy, it  is  usually  possible  to  determine  the  fact.  In  making  a 
diagnosis,  we  rely  upon  the  condition  of  the  following  parts  : — 

(1)  The  Breasts. — In  a  pregnant  nullipara,  the  breasts  are  firm 
and  smooth,  and  the  striae  present  are  recent,  and  are  conse- 
quently of  a  red  or  purplish  colour.  In  a  pregnant  parous  woman 
(i.e.,  a  woman  who  has  borne  children),  the  breasts  are  com- 
paratively flaccid  and  pendulous,  the  primary  areola  is  more 
marked,  and  the  nipple  is  longer  than  in  the  nulliparous  woman. 
There  are  both  recent  and  old  striae,  the  latter  of  a  pearly  white 
colour,  resembling  an  old  cicatrix.  The  intensity  of  these  differ- 
ences will,  however,  largely  depend  upon  whether  the  patient  has 
suckled  her  infant  or  not. 

(2)  The  Abdominal  Wall.  — In  a  nullipara,  the  abdominal  wall 


THE  DIAGNOSIS  OF  NULLIPARITY  OR  PARITY  237 

is,  like  the  breast,  smooth  and  tense,  there  is  no  marked  separa- 
tion of  the  recti,  and  only  recent  striae  are  present.  In  a  parous 
woman,  the  wall  is  flaccid  and  more  or  less  wrinkled,  the  recti  are 
as  a  rule  somewhat  separated,  and  there  are  both  old  and  recent 
stria?. 

(3)  The  Vulva. — In  virgins,  the  hymen  is  intact,  unless  there 
has  been  previous  surgical  interference  of  such  a  nature  as  to 
cause  its  rupture.  In  nulliparous  women,  who  are  not  virgins,  the 
hymen  is  almost  invariably  torn,  but  its  remains  can  readily  be 
found,  and  if  the  flaps  are  arranged  in  their  proper  position  the 


Fig.   139. — Diagram  of  Os  Uteri  in  a  Nullipara  as  seen  through  a 

Speculum. 

membrane  may  be  shown  to  be  complete.  In  a  parous  woman, 
on  the  other  hand,  the  hymen  is  not  only  torn,  but  has  almost 
entirely  disappeared,  and  is  only  represented  by  small  tags,  known 
as  carunculae  myrtiformes.  The  condition  of  the  hymen  is  not, 
however,  an  irrefragable  proof  of  either  virginity  or  parity.  It  is 
well  recognised  that  cases  may  occur  in  which  the  patient 
becomes  pregnant  without  rupture  of  the  hymen,  and  cases  have 
even  been  recorded  of  delivery  without  rupture  ;    while,  on  the 


238 


THE  PHYSIOLOGY  OF  PREGNANCY 


other  hand,  as  has  been  mentioned,  rupture  may  be  due  to 
surgical  interference.  Macnaughton-Jones*  describes  a  con- 
dition which  he  terms  '  folding  hymen,'  in  which  the  hymen, 
instead  of  lacerating,  folds  back  against  the  vaginal  wall  when 
pressed  upon,  and  when  the  pressure  is  removed  returns  into  its 
former  position.  Besides  the  condition  of  the  hymen,  there  are 
other  vulvar  changes.  In  nullipara?,  the  fourchette  is  intact  and 
the  perinaeum  unlacerated  ;   in  parous  women,  the  fourchette  is 


Fig.  140. 


-Diagram  of  Os  Uteri  in  a  Parous  Woman  as  seen 
through  a  speculum. 


almost  invariably  torn,  and  the  perinaeum  is  frequently  slightly 
lacerated  ;  the  fraenulum  is  also  often  torn,  and  minute  linear 
cicatrices  may  be  found  round  the  orifice  of  the  urethra  and  the 
head  of  the  clitoris. 

(4)  The  Vagina. — In  nulliparae,  the  vaginal  mucous  membrane  is 
rugose  ;  in  parous  women,  the  rugae  have  disappeared,  the  whole 
canal,  and  particularly  the  orifice,  is  larger,  and  cicatrices  may 
be  found  on  the  posterior  wall. 

*   '  Diseases  of  Women,'  eighth  edition,  p.  9. 


CALCULATION  OF  THE  DATE  OF  LABOUR  239 

(5)  The  Uterus. —  The  condition  of  the  cervix  is,  perhaps,  the 
most  important  sign  of  parity.  In  nulliparous  women,  the  orifice 
of  the  os  externum  is  circular  and  the  mucous  membrane  smooth 
and  intact.  In  parous  women,  the  orifice  is  a  transverse  slit,  with 
notched  edges  or  a  unilateral,  a  bi-lateral,  or  a  tri-radiate  tear,  due 
to  the  occurrence  of  lacerations.  The  body  of  the  uterus  is,  perhaps, 
more  relaxed  if  previous  pregnancies  have  occurred.  It  is  well 
to  point  out  that  cervical  changes  may  be  almost  or  entirely 
absent  if,  in  the  previous  pregnancy,  the  foetus  was  very  small, 
and  that,  on  the  other  hand,  a  linear  os  and  an  apparent  bi-lateral 
laceration  may  be  the  result  of  operative  division  of  the  cervix. 

The  Age  of  Pregnancy  and  the  presumed  Date  of 
Labour. 

As  soon  as  the  existence  of  pregnancy  has  been  ascertained, 
the  next  point  to  be  determined  is  the  age  of  pregnancy,  with  a 
view  to  predicting  the  date  of  delivery.  This  is  always  a  difficult 
matter  to  decide  with  certainty,  and  one  on  which  the  obstetrician 
should  never  be  too  positive.  We  have  already  seen  that  it  is 
not  possible  to  be  certain  when  pregnancy  commences,  and 
accordingly  it  is  correspondingly  difficult  to  determine  when  it 
it  will  end.  All  that  the  obstetrician  can  do  is  to  fix  on  an  approxi- 
mate date,  and  to  consider  it  as  the  middle  week  of  three  during 
which  delivery  may  take  place. 

The  probable  date  of  delivery  may  be  determined  in  four 
different  ways  : — From  the  date  of  last  menstruation  ;  from  the 
date  of  quickening ;  from  the  height  of  the  uterus  ;  and  from 
the  length  of  the  foetal  ovoid. 

(1)  From  the  Date  of  Last  Menstruation. — As  we  have  seen, 
pregnancy  may  be  considered  to  last  for  ten  lunar  months,  or 
280  days,  counting  from  the  first  day  of  the  last  menstruation, 
and  consequently,  if  we  count  forward  this  number  of  days,  we 
shall  arrive  approximately  at  the  date  of  delivery.  There  are 
many  ways  by  which  this  can  be  done,  but  perhaps  the  most 
simple  is  that  proposed  by  Matthews  Duncan.  He  counted 
forward  nine  months  from  the  last  day  of  the  last  menstruation, 
and  to  the  date  thus  obtained  added  three  days.  Thus,  if  the 
menstruation  which  began  on  July  1st  ended  on  July  5th,  then 
nine  months  and  three  days  added  on  brings  the  date  to  April  8th. 
If  we  wish  to  be  more  exact,  and  make  due  allowance  for  the 
difference  in  the  lengths  of  the  different  months,  we  can  adopt  the 
following  table  drawn  up  by  Galabin  : — 


Jan.  1  to  Oct.  1 
Feb.  1  to  Nov.  1 
Mar.  1  to  Dec.  1 
April  1  to  Jan.  1 
May  1  to  Feb.  1 
June  1  to  Mar.  1 
July  1  to  April  1 


is  273  (274)  days,  therefore  add  9  rhonths  and  5  (4)  days. 

is  273  (274)  ,,  ,,  ,,  5(4)     ,, 

is  275  ,,  „  ,,  3 

is  275  ,,  ,,  ,,  3 

is  276  ,,  ,,  ,,  2 

is  273  (274)  ,,  ,,  ,,  5(4)     ,, 

is  274  (275)  ,,  ,,  ,,  4(3)     ,, 


240 


THE  PHYSIOLOGY  OF  PREGNANCY 


Aug.  i  to  May  i  is  273  (274)  days,  therefore  add  9  months  and  5  (4)  days. 

Sept.  1  to  June  1  is  273  (274)  ,,  ,,  ,,  5  (4)     ,, 

Oct.  1  to  July  1  is  273  (274)  ,,  ,,  ,,  5  (4)     ,, 

Nov.  1  to  Aug.  1  is  273  (274)  ,,  ,,  ,,  5(4)     ,, 

Dec.  1  to  Sept.  1  is  274  (275)  ,,  ,,  ,,  4  (3)     ,, 

This  table  shows  the  number  of  days  between  a  fixed  date 
in  any  month  and  the  same  date  nine  calendar  months  sub- 
sequently, and  the  consequent  number  of  days  which  it  is 
necessary  to  add  on  in  order  to  reach  the  278th  day — the  figures 
in  brackets  are  to  be  used  in  leap  year.  '  Thus,  if  July  5th  be 
the  last  day  of  the  last  menstruation,  in  a  non-leap  year,  the 
subsequent  April  5th  will  be  274  days  on,  and,  if  four  days  are 
added  to  this,  a  date  278  days  from  the  date  of  last  menstruation 
is  obtained — i.e.,  April  9th.  The  difference  between  the  two 
methods  is  accounted  for  by  the  fact  that  the  former  does  not 
allow  for  the  loss  of  a  day  in  February. 

(2)  From  the  Date  of  Quickening. — This  is  an  unreliable  method 
of  determining  the  date  of  delivery  if  used  alone.  If,  however, 
it  is  used  as  an  adjunct  to  the  method  just  given,  it  is  of  assist- 
ance. Quickening,  as  we  know,  as  a  rule  occurs  during  the 
eighteenth  week.  Consequently,  if  we  add  on  twenty-two  weeks 
to  this  date,  we  shall  obtain  the  approximate  week  of  delivery. 
It  sometimes  happens  that  a  patient  may  be  unable  to  remember 
the  month  in  which  her  last  menstruation  occurred,  or  that  she 
is  uncertain  as  to  whether  what  she  considered  a  menstruation 
was  one  or  not,  and  consequently  an  error  of  a  month  may  be 
made  by  the  previous  method.  If  the  date  of  quickening  can 
be  reliably  ascertained,  it  will,  at  all  events,  show  from  what 
month  we  ought  to  count. 

(3)  The  Height  of  the  Uterus. — We  have  already  mentioned  the 
usual  height  of  the  uterus  above  the  symphysis  at  the  different 
months  of  pregnancy  as  ascertained  by  measurement.  For 
clinical  purposes  the  following  table  is,  however,  sufficiently 
accurate  : — 

At  the  end  of  2nd  month  the  uterus  is  the  size  of  a  large  orange. 


3rd 

,,               foetal  head  at  term. 

4th 

,       the  fundus 

is  halfway  between  the  symphysis 
the  umbilicus. 

and 

5th       , 

9                  >) 

two     fingers'     breadth     below 
umbilicus. 

the 

6th 

>                             >; 

at  the  umbilicus. 

7th        , 

)                             ) ) 

three  fingers'  breadth  above  the 
bilicus. 

um- 

8th 

J                            3? 

midway  between  the  umbilicus 
the  ensiform  cartilage. 

and 

9th     0, 

J                            )) 

up  to  the  ensiform  cartilage. 

oth        , 

■                             >J 

same  as  at  eighth  month. 

As  the  uterus  reaches  approximately  the  same  height  at  the  end 
of  the  eighth  and  of  the  tenth  month,  it  is  necessary  to  be  able  to 
distinguish  between  the  two.  At  the  eighth  month,  the  abdomen 
is  less  prominent  and  is  perceptibly  smaller  than  it  subsequently 


CALCULATION  Ob'  THE  DATE  OF  LABOUR 


241 


is  at  the  tenth.  The  patient  also,  if  questioned,  will  tell  us  during 
the  eighth  month  that  the  symptoms  caused  by  the  pressure  of 
the  uterus  against  the  diaphragm  are  increasing  from  day  to  day, 
while  during  the  tenth  month  they  are  diminishing. 

(4)  The  Length  of  the  Foetal  Ovoid. — The  length  of  the  foetal 


Fig.   141. — The  Height  of  the  Uterus  at  the  Different  Weeks  of 
Pregnancy.     (Dickinson.) 


ovoid  can  be  directly  measured  during  the  second  half  of  preg- 
nancy by  placing  one  blade  of  a  calipers  on  the  pelvic  pole  of  the 
foetus  per  vaginam,  and  the  other  blade  on  the  abdominal  wall  in 
close  contact  with  the   fundal  pole.     The  following  table  gives 

16 


242 


THE  PHYSIOLOGY  OF  PREGNANCY 


26, 

28, 

30, 

32, 

34. 

36, 

38, 

40. 

72, 

7'6, 

79, 

8'3. 

8-8, 

9-2, 

95. 

97 

the  average  length    of  the   foetal   ovoid   as   ascertained   in   this 
manner : — 

Week  of  pregnancy 
Length  of  foetus  in  inches  - 

This  method  can  be  adopted  in  cases  in  which  it  is  of  consider- 
able importance  to  gain  a  correct  idea  of  the  age  of  pregnancy  or 
of  the  size  of  the  foetal  ovoid.  In  ordinary  practice,  however, 
it  entails  more  vaginal  manipulation  than  is  either  necessary  or 
advisable. 

In  cases  in  which  the  ovum  has  been  expelled,  its  age  can  be 
ascertained  by  direct  measurement  of  the  length  of  the  embryo 


Fig.  142. 


-Diagram  showing  Method  of  measuring  the  Length 
of  the  Fcetus  in  utero  with  Calipers. 


or  foetus.  The  following  rule  furnishes  an  easy  way  of  remem- 
bering the  foetal  length  at  the  end  of  the  different  months  : — To 
obtain  the  length  of  the  foetus  in  centimetres  for  each  month  up 
to  the  fifth,  square  the  number  of  the  month ;  after  the  fifth, 
multiply  the  number  of  the  month  by  five.  Thus,  at  the  end  of 
the  third  month,  the  length  of  the  foetus  is  3  by  3  centimetres — 
i.e.,  9  centimetres;  at  the  end  of  the  seventh  it  is  7  by  5  centi- 
metres— i.e.,  35  centimetres. 


THE  CONDITION  OF  THE  FCETUS  243 

The  Situation  of  the  Pregnancy. 

It  is  most  important  to  determine  whether  we  are  dealing  with 
an  intra-  or  extra-uterine  pregnancy.  It  is  true  that  in  cases  which 
are  apparently  normal  it  is  not  customary  to  submit  the  patient 
to  the  necessary  examination  for  determining  this  point,  but,  if  any 
symptoms  occur  which  suggest  the  possibility  of  an  extra-uterine 
pregnancy,  such  an  examination  should  always  be  made.  We 
shall  not  here  refer  to  the  diagnosis  of  an  extra-uterine  pregnancy, 
as  it  will  be  more  suitably  dealt  with  in  the  chapter  on  that 
condition. 

Single  or  Multiple  Pregnancy. 

It  is  always  well  when  examining  a  pregnant  patient  to  deter- 
mine, if  possible,  whether  we  are  dealing  with  a  case  of  single  or 
multiple  pregnancy.  The  diagnosis  can  be  best  made  by  ausculta- 
tion and  abdominal  palpation.  There  is  only  one  certain  method 
of  diagnosing  the  existence  of  twins  prior  to  delivery  : — if  two 
observers,  listening  at  the  same  time,  hear  and  count  two  fcetal 
hearts  and  find  that  their  results  do  not  correspond.  If,  however, 
monsters  are  excluded,  the  palpation  of  two  foetal  heads,  or 
breeches,  or  of  more  than  two  large  parts — i.e.,  either  a  head  or 
a  breech,  or  of  more  than  four  limbs,  is  conclusive  evidence  that 
there  is  more  than  one  foetus.  It  is  rarely  possible  to  diagnose  the 
existence  of  triplets,  though  it  doubtless  has  been  done.  The 
only  method  of  so  doing  would  be  the  recognition  of  three 
distinct  foetal  hearts  by  careful  auscultation.  Abdominal  palpa- 
tion in  such  cases  will  not  afford  much  assistance  on  account  of 
the  small  size  of  each  foetus. 

The  Condition  of  the  Foetus. 

In  the  early  months  of  pregnancy,  we  can  infer  the  continued 
life  of  the  foetus  so  long  as  there  is  no  interruption  to  the  course 
of  pregnancy,  and  so  long  as  the  patient's  symptoms  continue  to 
be  those  of  normal  pregnancy.  In  almost  all  cases,  if  the  foetus 
dies,  the  ovum  is  expelled  either  in  part  or  altogether.  If  it  is 
retained,  as  may  happen,  a  condition  of  missed  abortion  or  labour 
occurs  according  to  the  period  of  pregnancy.  In  either  case,  the 
symptoms  of  the  patient  will  sooner  or  later  call  attention  to  her 
condition.  There  is  usually  a  brown  discharge  from  the  uterus, 
or,  perhaps,  slight  recurrent  haemorrhages.  If  the  membranes  have 
ruptured,  the  discharge  may  be  putrid.  The  growth  of  the  uterus 
ceases,  and,  if  the  condition  persists,  the  uterus  diminishes  in  size 
consequent  upon  the  absorption  of  the  liquor  amnii.  The  breasts 
become  flaccid  and  the  secondary  areola  disappears.  If  the 
patient  is  in  the  last  four  months  of  pregnancy  and  no  foetal  heart 
can  be  heard,  even  on  the  most  careful  examination,  the  foetus  is 
probably  dead.     If  on  making  a  vaginal  examination  the  cranial 

16 — 2 


244  THE  PHYSIOLOGY  OF  PREGNANCY 

bones  are  found  to  be  loose  and  movable  beneath  the  scalp,  the 
foetus  is  certainly  dead.  The  subjective  symptoms  of  the  patient 
are  also  of  importance.  Her  general  health  suffers  in  consequence 
of  the  absorption  of  ptomaines  from  the  dead  foetus,  and  in  pro- 
portion to  the  size  of  the  latter  and  the  time  it  has  been  dead. 
She  complains  of  loss  of  appetite,  debility,  and  of  various  un- 
pleasant sensations,  such  as  chills,  a  disagreeable  taste  in  the 
mouthj  unpleasant  dreams,  and  such  like.  The  movements  of 
the  foetus  are  no  longer  felt,  and,  in  some  cases,  the  patient  may 
give  a  definite  history  of  having  felt  them  as  usual  up  to  a  certain 
date,  when  they  became  more  violent  than  they  had  formerly 
been,  and  then  ceased.  In  appearance,  she  is  sallow,  or  even 
slightly  jaundiced.  If  decomposition  of  the  ovum  has  occurred, 
the  usual  symptoms  of  sapraemic  poisoning  follow. 

If,  on  the  other  hand,  the  foetus  lives  and  develops  in  the  normal 
manner  it  is  usually  always  possible  to  detect  the  foetal  heart,  if 
the  sixth  month  is  passed,  and  to  appreciate  foetal  movements  if 
we  examine  for  a  sufficient  length  of  time. 

The  Presence  of  Complications. 

The  final  step  in  the  diagnosis  of  pregnancy  consists  in  ascer- 
taining the  presence  or  absence  of  complications.  The  different 
methods  by  which  we  obtain  this  information  have  been  already 
described  (vide  Part  II.,  Chap.  III.),  and  need  not  be  repeated. 
Here,  it  is  only  necessary  to  insist  upon  the  early  recognition 
of  complications,  as  by  so  doing  their  prognosis  is,  in  many 
instances,  greatly  improved.  It  may  appear  to  the  student  as 
if  the  necessary  examination  for  the  elimination  of  all  possible 
complications  would  be  so  long  and  severe  that  no  patient  would 
consent  to  it.  This  is  not  so.  With  experience,  it  soon  becomes 
possible  to  ascertain  from  the  appearance  of  the  patient  and  the 
answers  to  a  few  questions,  whether  it  is  necessary  or  not  to 
inquire  minutely  into  any  special  point.  Thus,  it  is  manifestly 
unnecessary  to  examine  a  patient  to  determine  whether  the  pelvis 
is  contracted,  if  she  has  already  been  normally  delivered  of  a 
full-term  living  child,  or  to  make  a  vaginal  examination  to  deter- 
mine the  existence  of  inflammatory  conditions,  if  she  is  free  from 
all  symptoms  of  such  conditions.  We  must  always  bear  in  mind 
the  necessity  for  excluding  the  presence  of  complications,  but, 
with  due  knowledge  of  the  symptoms  arising  from  these  condi- 
tions, it  is  usually  always  possible  to  do  so  in  normal  cases 
without  subjecting  the  patient  to  a  prolonged  examination. 


CHAPTER  III 
THE  HYGIENE  OF  PREGNANCY 

The  Dietary—The  Eliminatory  Functions  of  the  Body— The  Use  of  Baths 
—  Vaginal  Douching  —  Dress  —  Coition  —  The  Mental  Condition  and 
Surroundings  of  the  Pregnant  Woman — Surgical  Operations  during 
Pregnancy — The  Care  of  the  Breasts. 

In  considering  the  management  and  hygiene  of  pregnancy,  it 
cannot  be  too  strongly  insisted  upon  that  pregnancy  is  a  physio- 
logical condition,  and  not  a  '  nine  months'  disease.'  All  that  is 
necessary  during  normal  pregnancy  is  to  see  that  the  ordinary 
physiological  functions  of  the  body  are  properly  discharged,  and 
that  due  attention  is  paid  to  the  fulfilment  of  the  physiological 
requirements  of  the  body.  It  is  a  distinct  misfortune  when,  in  a 
normal  case  of  pregnancy,  a  woman  considers,  or  is  led  by  her 
friends  to  consider,  that  she  is  a  '  patient,'  as  such  a  consideration 
causes  her  to  dwell  too  much  upon  her  condition,  and,  perhaps, 
to  alter  her  normal  mode  of  living  in  a  manner  which  may  be  far 
from  advisable.  The  notion  '  that  a  woman  only  escapes  being 
ill  twelve  times  a  year  by  having  an  illness  which  lasts  for  nine 
months,'  has  been  in  the  past  responsible  for  many  feminine 
derangements.  We  must  not,  however,  be  understood  to  mean 
by  this  that  a  woman  during  pregnancy  may  continue  in  all  the 
occupations  which  she  may  follow  at  other  times.  The  occupa- 
tions which  many  women  follow  are  very  far  from  natural — that 
is  to  say,  they  involve  habits  and  surroundings  very  different 
from  those  which  are  calculated  to  maintain  the  body  in  the 
natural  hygienic  conditions,  and  all  such  occupations  are  directly 
opposed  not  alone  to  the  health  of  the  woman,  but  to  the  health 
of  her  offspring.  Giles  aptly  remarks  that  '  there  is  no  doubt 
that  in  the  majority  of  cases  women  require  to  be  treated  with 
an  extra  degree  of  consideration  and  indulgence  during  menstrua- 
tion, whilst  many  are  temporarily  unfitted  for  arduous  work  or 
special  exertion,'*  a  remark  which  is  even  more  applicable  to 
pregnancy.  To  slightly  modify  Ballantyne's  f  words  : — The  fact 
that  our  advice  consists  largely  of  the  recommendation  that  all 
the  laws  of  health,  which  apply  to  the  non-pregnant  condition, 

*  '  Menstruation  and  its  Disorders,'  p.  31. 
f  '  Antenatal  Pathology  and  Hygiene,'  p.  471. 
245 


246  THE  PHYSIOLOGY  OF  PREGNANCY 

should  be  specially  enforced  in  the  pregnant  state  must  not  be 
interpreted  as  permission  to  the  pregnant  woman  to  continue  dis- 
regarding many  of  the  laws  of  health,  just  as  she  did  when  non- 
pregnant. 

The  dietary  of  pregnancy  should  be  simple,  ample,  and 
nourishing,  and  all  indigestible  foods  should  be  avoided,  but  at 
the  same  time  there  should  be  no  undue  restrictions  or  excess. 
Plenty  of  fluid  may  be  drunk,  as  it  helps  the  action  of  the 
kidneys,  but  the  excessive  use  of  tea  or  coffee,  as  of  alcoholic 
liquids,  must  be  forbidden.  A  small  quantity  of  alcohol  may  be 
taken  daily  if  the  patient  is  in  the  habit  of  doing  so  under  other 
circumstances ;  but,  on  the  whole,  it  is  perhaps  as  well  to  limit  its 
use  as  far  as  possible. 

The  regular  action  of  the  eliminatory  functions  of  the  body  is 
of  very  great  importance.  If  the  skin,  the  kidneys,  and  the 
bowels  do  not  act  sufficiently,  the  most  serious  complications  of 
pregnancy  may  arise.  The  patient  should  in  all  cases  be  warned 
of  the  importance  of  this,  and  especially  of  the  importance  of 
noting  a  sudden  or  gradual  diminution  in  the  amount  of  urine 
which  is  passed  daily.  If  she  is  troubled  by  constipation,  the 
regular  action  of  the  bowels  should  be  ensured  by  the  use  of 
laxatives  or  mild  purgatives.  For  this  purpose,  cascara  sagrada, 
apenta  water,  or  aloin  may  be  recommended  ;  but  all  drastic 
carthartics  must  be  avoided,  both  on  account  of  their  weakening 
effect  upon  the  patient,  and  the  danger  that  they  may  interfere 
with  the  course  of  pregnancy.  If  the  kidneys  do  not  act  suffi- 
ciently, the  amount  of  fluid  should  be  increased — particularly  such 
fluids  as  barley-water  or  plain  water,  the  action  of  the  skin  must 
be  encouraged  by  hot  baths  or  vapour  baths  and  warm  clothing, 
and  perhaps  elimination  assisted  by  the  administration  of  hydra- 
gogue  purgatives. 

The  proper  use  of  baths  for  purposes  of  personal  cleanliness  is 
also  of  importance.  Whenever  possible,  a  warm  bath  should  be 
taken  daily,  and  the  genitals  should  be  bathed  night  and  morning 
with  warm  water,  to  which  some  mild  antiseptic  astringent,  such 
as  Sanitas,  has  been  added.  Extremes  of  temperature  must  be 
avoided,  though,  according  to  some  authorities,  if  the  woman  is 
in  the  habit  of  taking  cold  baths  in  the  morning,  their  use  may 
be  continued. 

The  question  as  to  the  advisability  of,  or  the  necessity  for, 
vaginal  douching  during  pregnancy  is  one  on  which  we  fancy 
most  authorities  in  these  countries  are  agreed  that  it  is  unneces- 
sary and,  hence,  inadvisable  save  under  special  conditions. 
Abroad,  however,  there  is  a  tendency  in  some  quarters  to  recom- 
mend their  use  (Ribemont-Dessaignes).  We  have  already  dis- 
cussed the  habitual  use  of  douches  during  labour,  and  all  that 
is  necessary  to  say  here  is  that  if  they  are  not  required  during 
normal  labour,  they  certainly  are  not  required  during  normal 
pregnancy.     If,  however,  the  patient   suffers   from   leucorrhceal 


THE  HYGIENE  OF  PREGNANCY 


247 


discharge,  their  use  is  frequently  advisable  as  part  of  the  treat- 
ment of  the  condition  which  gives  rise  to  the  discharge.  In  such 
cases,  the  douche  should  be  administered  at  a  low  pressure,  and 
should  contain  an  unirritating  and  antiseptic  astringent.  A  weak 
solution  of  Sanitas  is  well  suited,  and  pyroligneous  acid  or  a 
weak  solution  of  sulphate  of  copper  may  also  be  used.  If 
vaginal  douching  is  ordered  for  a  patient,  the  method  in  which 
the  douche  is  to  be  administered  must  also  be  clearly  specified, 
as  it  is  most  inadvisable  to  allow  patients  to  use  a  douche  unless 
they  take  the  necessary  precautions  to  ensure  cleanliness  in  its 
administration.  For  personal  use  by  the  patient,  a  small  metal  or 
glass  container,  with  a  rubber  connecting-tube,  hung  against  the 
wall,  or  placed  upon  a  stand  two  to  three  feet  above  the  position 
which  the  patient's  hips  will  occupy,  are  all  that  is  required.  A 
glass  nozzle  should  be  used,  as  it  can  be  boiled.  The  douche- 
container  and  tube  should  be  washed  out  after  use  with  water,  to 
which  washing-soda  has  been  added.  The  temperature  of  the 
douche  should  not  exceed  980  F. 

The  dress  during  pregnancy  should  be  such  that  pressure 
upon  the  abdomen  is  avoided.  So  far  as  possible,  all  under- 
clothing should  be  supported  from  the  shoulders,  and  not  round 
the  waist.  Corsets,  if  worn,  must  be  so  adapted  to  the  figure 
that  they  give  support,  but  do  not  exert  compression.  In  most 
cases,  and  in  all  cases  in  which  the  abdomen  is  pendulous,  or 
the  recti  widely  separated,  the  use  of  a  well-fitting  abdominal  belt, 
so  adjusted  as  to  support  the  abdomen  from  below,  is  advisable. 
Garters  must  not  be  worn,  as  they  increase  the  tendency  to 
venous  congestion  of  the  legs. 

Regular  exercise  in  the  open  air  is  a  most  essential  part  of  the 
hygiene  of  pregnancy.  The  exercise  should  be  of  the  same 
character  as  that  to  which  the  woman  is  accustomed  at  other 
times,  with  the  restriction  that  violent  exercises  of  all  kinds 
should  be  forbidden.  The  question  of  the  permissibility  of  bicycle- 
riding  during  pregnancy  is  one  on  which  the  medical  man  is 
often  consulted.  There  can  be  little  question  that  in  the  last 
few  months  of  pregnancy  it  is  unwise,  and,  indeed,  there  are 
but  few  women  who  would  care  to  attempt  it  at  such  a  time. 
In  the  early  months,  and  on  good  roads,  there  does  not  seem 
to  be  any  objection  to  it  in  a  moderate  degree,  provided  that  it 
does  not  give  rise  to  undue  fatigue  or  to  discomfort.  In  all  cases 
in  which  it  gives  rise  to  breathlessness,  or  in  which  there  is  any 
tendency  to  venous  congestion  of  the  legs,  it  is  inadvisable.  In 
the  case  of  multipara?,  the  history  of  previous  pregnancies  will  to 
a  large  extent  guide  us  in  the  exercise  which  may  be  permitted. 
In  the  case  of  patients  who  have  had  previous  abortions,  sudden 
exertions  must  be  prevented,  so  far  as  possible,  and  any  exercise 
forbidden  which  necessitates  sudden  movements  of  the  body  as 
would  occur  in  the  case  of  bicycle-riding.  In  all  cases,  long 
standing  or  undue  prolongation  of  exercise  should  be  avoided. 


248  THE  PHYSIOLOGY  OF  PREGNANCY 

The  question  of  the  permissibility  of  coition  during  pregnancy 
is  an  important  one,  although  it  is  not  always  probable  that 
medical  advice  in  this  respect  will  be  acted  upon.  There  is  no 
question  that  in  certain  cases  coition  is  inadvisable,  and  in  all 
cases  in  which  there  is  a  history  of  previous  abortion  it  should 
be  strictly  forbidden.  Many  authorities  forbid  it  during  the  first 
four  months.  If  the  analogy  of  the  lower  animals  and  of  many 
savage  races  is  to  be  followed,  coitus  should  be  entirely  forbidden. 
In  this  connection,  we  recommend  a  perusal  of  the  remarks  of 
Parvin.* 

The  mental  condition  and  the  surroundings  of  the  pregnant 
woman  are  of  importance,  inasmuch  as  they  largely  influence  her 
physical  well-being  and  hence  that  of  the  foetus.  A  pregnant 
woman  should,  as  far  as  possible,  be  sheltered  from  all  influences 
which  tend  to  give  rise  to  excitement,  annoyance,  or  depression. 
The  effect  of  maternal  impressions  on  the  foetus  is  not  yet  clearly 
understood,  but  there  can  be  no  doubt  that,  if  mental  conditions  are 
sufficient  to  interfere  with  the  appetite,  sleep,  and  general  health 
of  the  woman,  they  must  also  prejudicially  affect  the  foetus.  All 
amusements  or  occupations,  which  necessitate  the  presence  of  the 
woman  in  an  atmosphere  in  which  an  undue  amount  of  carbonic 
acid  gas  or  carbon  monoxide  gas  is  present,  must  be  rigidly  for- 
bidden, as  the  association  between  the  accumulation  of  these  gases 
in  the  blood  and  the  liability  to-abort  is  well  recognised.  Similarly, 
all  occupations  which  bring  the  patient  into  constant  contact  with 
certain  poisons,  notably  lead,  mercury,  and  phosphorus,  must  be 
temporarily  abandoned. 

The  question  of  the  permission  of  surgical  operations  during 
pregnancy  is  one  on  which  the  obstetrician  is  often  called  to  give 
an  opinion,  and  is  closely  connected  with  similar  questions  regard- 
ing exercise  and  coitus.  In  healthy  patients,  in  whom  there  is 
no  tendency  to  abort,  and  on  whom  the  mental  effect  is  not  too 
strongly  marked,  the  risk  that  a  minor  surgical  operation  will 
cause  abortion  is  extremely  small.  If  an  operation  can  be  post- 
poned until  a  few  months  after  the  labour,  without  any  prej  udicial 
effect  upon  the  health  of  the  patient,  by  all  means  let  it  be  post- 
poned, but  if  the  operation  is  called  for  to  remove  some  condition 
which  causes  immediate  suffering  or  ill-health,  it  should  be  per- 
formed. An  anaesthetic  should  always  be  administered,  and  in 
this  connection  it  may  be  mentioned  that '  while  there  is  no  reason 
to  doubt  the  passage  of  either  chloroform  or  ether  to  the  foetus, 
neither  is  there  any  reason  to  apprehend  toxic  effects  unless  the 
maternal  anpesthesia  is  deep  and  long-continued'  (Ballantynef). 

The  care  of  the  breasts  during  pregnancy  is  of  importance. 
At  no  time  should  the  corset  or  other  garment  be  allowed  to 
press  upon  them,  as  this  interferes  with  their  development  and 
prevents  the  formation  of  a  proper  nipple.    During  the  last  month 

*  'Science  and  Art  of  Obstetrics,'  first  edition,  p.  212. 
•f   Op.  cit.,  p.  269. 


THE  HYGIENE  OF  PREGNANCY  249 

of  pregnancy,  the  patient's  attention  must  be  directed  to  two 
points — the  hardening  of  the  skin  of  the  nipple  and  the  formation 
of  a  proper  nipple.  If  this  is  not  done,  when  she  commences  to 
suckle  the  infant  she  will  find  that  the  dragging  of  the  latter  will 
cause  small  lacerations  and  excoriations  of  the  skin — conditions 
which  are  sometimes  extremely  painful,  and  that  if  the  nipple  is 
not  properly  formed  the  infant  cannot  take  it  in  its  mouth.  In 
order  to  harden  the  skin,  the  nipples  should  be  bathed  with  an 
alcoholic  lotion  a  couple  of  times  a  day,  such  as  whisky  or  equal 
parts  of  eau-de-Cologne  and  water.  In  order  to  form  proper 
nipples,  the  woman  should  be  taught  to  draw  them  out  gently 
with  her  fingers  several  times  a  day.  In  so  doing,  no  force  must 
be  used,  and  care  must  be  taken  that  the  fingers  are  clean.  Rough 
manipulation  may  result  in  the  occurrence  of  small  lacerations, 
and,  if  these  become  infected,  mastitis  may  follow. 


PART    IV 
THE    PHYSIOLOGY   OF    LABOUR 


CHAPTER  I 
THE  CAUSATION  AND  PHENOMENA  OF  LABOUR 

Definition — Time  of  Onset  of  Labour — The  Causes  of  Labour — The  Stages 
of  Labour — The  Phenomena  of  Labour  ;  The  Contractions  of  the  Uterus  ; 
The  Contractions  of  the  Accessory  Muscles  ;  The  Effect  of  the  Uterine 
Contractions  on  the  Uterus,  on  the  Pelvic  Contents,  on. the  Perinaeum 
and  Neighbouring  Structures,  on  the  Pelvic  Bones,  on  the  Ovum,  on 
the  Maternal  System  generally. 

'  Labour  '  is  the  term  applied  to  the  process  which  severs  the 
connection  between  the  ovum  and  the  mother  by  removing  the 
former  from  the  organism  of  the  latter. 

As  has  been  already  seen,  the  average  duration  of  pregnancy  is 
280  days,  or  forty  weeks,  or  ten  lunar  months.  Labour  may, 
however,  occur  at  any  time  during  these  ten  months,  or  even  after 
a  longer  period,  as  in  the  rare  cases  of  protracted  pregnancy. 
Accordingly,  labour  is  divided  into  the  following  classes,  in  accord- 
ance with  the  period  of  pregnancy  at  which  it  occurs  : — 

(r)  Abortion.- — If  labour  comes  on  during  the  first  four  months 
of  pregnancy — i.e,  before  the  full  formation  of  the  placenta — it  is 
termed  abortion. 

(2)  Partus  Immaturus. — If  labour  comes  on  between  the  end  of 
the  fourth  and  the  end  of  the  seventh  lunar  month — i.e.,  after  the 
placenta  has  formed,  but  before  the  foetus  becomes  viable— it  is 
termed  partus  immaturus,  or  miscarriage. 

(3)  Partus  Prematurus.- — If  labour  comes  on  between  the  end 
of  the  seventh  month  and  the  end  of  the  tenth  month — i.e.,  after 
the  foetus  has  become  viable,  but  before  full  term  is  reached — it 
is  termed  partus  prematurus,  or  premature  birth. 

(4)  Partus  Maturus. — If  labour  comes  on  at  the  end  of  the  tenth 
month — i.e.,  at  full  term — it  is  termed  partus  maturus,  or  full-term 
birth. 

(5)  Partus  Serotinus. — If  labour  does  not  occur  until  after  the 
end  of  the  tenth  month — i.e.,  after  full  term — it  is  known  as  partus 
serotinus,  or  delayed  birth. 

The  Causes  of  Labour. — The  immediate  cause  of  labour  is  the 
occurrence  of  uterine  contractions,  as  it  is  to  these  that  the 
expulsion  of  the  ovum  is  due,  and  under  normal  circumstances 
these  contractions  occur  at  the  end  of  the  tenth  month.  Accord- 
ingly, our  inquiry  into  the  causes  of  labour  resolves  itself  into 

253 


254  THE  PHYSIOLOGY  OF  LABOUR 

two  questions  : — What  causes  uterine  contractions  ?  Why  do 
they  normally  occur  at  the  end  of  the  tenth  month  ? 

As  we  have  already  seen,  the  uterus  is  innervated  by  three  sets 
of  nerves  : — 

(i)  A  set  derived  from  the  cord  through  the  sacral  nerves,  and 
under  the  control  of  one  centre  in  the  medulla  oblongata,  and  of 
another  in  the  lumbar  spine. 

(2)  A  set  derived  from  the  aortic,  mesenteric,  and  hypogastric 
sympathetic  plexuses,  which  join  the  uterine  plexus  in  front  of  the 
aorta. 

(3)  A  set  derived  from  independent  ganglia  (Dembo's  ganglia) 
situated  near  the  anterior  vaginal  fornix  (Schaeffer). 

Stimuli  are  carried  to  the  uterus  through  these  nerves  as  the 
result  of  direct  irritation  of  the  motor  centre  in  the  medulla,  or 
of  reflex  irritation  of  the  centre  in  the  lumbar  cord  or  of  the 
sympathetic  ganglia.  Direct  irritation  of  the  motor  centre  in  the 
medulla  is  known  to  be  caused  by  certain  substances  circulating 
in  the  blood — excess  of  C02,  quinine,  sodium  salicylate,  ergot, 
strychnine,  and  other  drugs ;  by  sudden  or  extreme  elevation 
of  temperature ;  and  by  the  occurrence  of  profuse  haemorrhage. 
Reflex  irritation  of  the  lumbar  centres,  or  of  the  sympathetic 
ganglia,  can  be  caused  by  dilatation  of  the  cervix  uteri,  detach- 
ment of  the  membranes,  excess  of  C02  in  the  blood  in  the 
uterine  sinuses,  irritation  of  the  breasts,  and,  possibly,  the 
monthly  irritation  associated  with  the  menstrual  cycle,  even 
though  menstruation  itself  is  temporarily  iatent.  Any  of  these 
stimuli  may  be  the  cause,  or  one  of  the  associated  causes,  of  the 
onset  of  uterine  contractions.  It  is  not  even  necessary  that  there 
should  be  a  connection  with  the  brain  or  the  centre  in  the  medulla, 
as  has  been  proved  not  only  experimentally,  but  also  clinically,  in 
cases  in  which  the  spinal  cord  had  been  severed  above  the  lumbar 
region  by  tumours. 

It  is  a  very  much  more  difficult  matter  to  determine  why 
uterine  contractions  occur  normally  at  the  end  of  the  tenth  month. 
Indeed,  it  is  doubtful  that  any  explanation  which  can  be  given  at 
the  present  time  can  be  regarded  as  quite  satisfactory.  It  is  very 
improbable  that  there  is  any  one  definite  cause  for  the  onset  of 
uterine  contractions  at  full  term.  We  have  seen  that  there  are 
a  considerable  number  of  separate  agencies  by  which  uterine  con- 
traction can  be  provoked,  and  it  is  most  likely  that  the  onset  of 
full-term  labour  is  due  to  an  association  of  several  of  them.  If  it 
was  otherwise,  and  if  the  normal  onset  of  labour  was  due  to  one 
factor  alone,  it  would  be  difficult  to  account  for  its  regularity,  as 
there  is  no  agency  of  which  we  at  present  know  which  is  always 
present  in  the  same  degree.  The  normal  agencies  which  assist  in 
causing  uterine  contractions  at  full  term,  and  the  manner  in  which 
they  occur,  are,  in  all  probability,  as  follows : — 

(1)  Dilatation  of  the  Cervix. — In  the  early  months  of  pregnancy, 
increase  in  the  size  of  the  uterus  is  caused  and  accompanied  by 


THE  CAUSES  OF  LABOUR  255 

hypertrophy  of  its  walls.  Consequently,  instead  of  a  thinning  of 
the  uterine  walls  taking  place,  there  is  an  actual  increase  in  thick- 
ness. In  the  later  months,  on  the  other  hand,  further  increase  in 
the  size  of  the  uterus  is  obtained  at  the  expense  of  the  thickness  of 
the  uterine  walls,  and  the  latter  become  thinned  and  tense.  As 
this  process  cannot  continue  indefinitely,  it  is  plain  that  a  time 
must  come  at  which  the  uterus  commences  to  offer  an  obstacle  to 
the  increase  in  size  of  the  ovum  and  to  press  the  latter  against 
the  lower  uterine  segment  and  the  internal  os.  This  brings  about 
a  commencing  dilatation  of  the  internal  os,  and  so  creates  one  of 
the  agencies  by  which  contractions  are  provoked.  It  has  been 
suggested  by  certain  writers  that  this,  perhaps,  is  the  agency,  and 
that  it  is  unnecessary  to  look  further  for  others.  That  this  cannot 
be  so  is,  however,  sufficiently  obvious  from  the  fact  that  in  some 
cases — e.g.,  twins  orhydramnios — the  uterus  will  bear  an  extreme 
degree  of  dilatation  without  reaction.  That  it  is  a  possible 
agency  is  also  obvious,  if  we  consider  the  result  of  artificial 
dilatation  of  the  cervix  during  pregnancy. 

(2)  Detachment  of  the  Membranes. — The  theory  that  separation 
of  the  membranes  occurs  during  the  last  month  of  pregnancy  as 
a  result  of  degenerative  changes  in  the  decidua  has  been  looked 
on  with  favour  by  many  authorities.  Such  a  change  may  be  due 
to  fatty  degeneration  (Simpson,  Schroeder),  or  to  a  coagulation 
necrosis  which  gives  rise  to  a  fibrinous  transformation  or  degenera- 
tion (Webster).  If  sufficient  change  takes  place  in  the  decidua 
to  cause  the  detachment  of  the  membranes,  an  agency  in  the 
causation  of  uterine  contractions  is  undoubtedly  created.  In 
practice,  we  find  that  the  manual  or  instrumental  separation  of 
the  membranes  is  almost  always  followed  by  labour.  It  would 
appear  as  if  the  ovum  in  such  cases  became  akin  to  a  foreign 
body  and  caused  a  peripheral  irritation  of  the  nerve  endings.  In 
addition  to  fatty  degeneration  or  coagulation  necrosis  of  the 
decidua,  the  formation  of  the  lower  uterine  segment  may  also 
cause  the  detachment  of  the  membranes  which  form  the  lower 
pole  of  the  ovum. 

(3)  Excess  of  CO 2  in  the  Uterine  Sinuses. — The  appearance  of 
large  nucleated  masses  in  the  decidua  serotina  has  been  noted 
during  the  fifth  month  of  pregnancy.  These  masses,  which  are 
probably  derived  from  the  syncytium,  increase  in  number  during 
the  following  months,  and,  about  the  eighth  or  ninth  month,  are 
said  to  grow  into  the  veins  which  carry  the  return  flow  of  blood 
from  the  placenta  (Friedlander,  Leopold)  and  to  produce  a  partial 
blockage  of  them.  This  necessarily  results  in  a  slowing  of  the 
circulation  of  blood  through  the  uterine  sinuses,  and  hence  in  the 
accumulation  in  this  blood  of  an  increased  amount  of  C02.  The 
effect  of  an  excess  of  C02  when  contained  in  the  placental  blood 
has  been  shown  by  Hasse,*  while  Runget  attributes  the  occur- 

*  Hasse,  Zeitschrift  f.  Gyncih.  und  Geburtsh.,  vi.  1,  1881. 

f  Runge,  Ibid.,  iv.  71,  1881;  Centralb.  f.  Gyncik.,  1883,  No.  21,  329. 


256  THE  PHYSIOLOGY  OF  LABOUR 

rence  of  contractions  not  so  much  to  the  excess  of  C02  as  to  the 
accompanying  lack  of  oxygen. 

(4)  Excess  of  CO 2  in  the  General  Circulation. — An  increased  pro- 
portion of  C02  in  the  general  circulation  naturally  tends  to  occur 
towards  the  end  of  pregnancy,  in  consequence  of  the  ever- 
increasing  quantity  of  oxygen  used  by  the  growing  foetus. 
There  is  good  reason  to  consider  that  excess  of  C02  will  cause 
the  onset  of  labour  in  consequence  of  the  comparative  frequency 
with  which  fatal  cases  of  poisoning  by  this  agency  have,  in  the 
case  of  pregnant  women,  been  attended  by  the  expulsion  of  the 
foetus.  Further,  Brown-Sequard  excited  contractions  of  the  uterus 
in  the  case  of  pregnant  animals  by  this  means.  It  is  probable 
that  this  effect  is  produced  by  the  direct  action  of  C02  on  the 
motor  centre  in  the  medulla,  but  a  reflex  action  through  the 
uterine  nerve  endings,  as  has  been  described,  may  also  take 
place. 

(5)  Menstrual  Irritation. — All  through  pregnancy,  the  uterus 
shows  by  the  occurrence  of  painless  contractions  that  it  possesses 
a  certain  degree  of  irritability.  As  a  rule,  these  contractions  are 
more  marked  at  each  menstrual  period,  thus  showing  that  the 
nervous  mechanism  of  menstruation  is  still  active  to  a  slight 
degree  even  though  menstruation  itself  is  latent.  This  monthly 
irritability  of  the  uterus,  though  not  sufficient  in  itself  to  cause 
the  onset  of  true  uterine  contractions,  furnishes  an  agency  which, 
in  association  with  others,  may  be  capable  of  determining  the 
date  of  their  commencement. 

Accordingly  we  see  that,  in  association  with  a  normal  preg- 
nancy, there  are  a  number  of  changes  in  the  maternal  organism 
and  in  the  ovum,  which  become  daily  more  marked  and  which 
apparently  tend  to  reach  a  climax  and  to  cause  uterine  contrac- 
tions. The  fact  that  one  of  these  phenomena — i.e.,  the  occurrence 
of  painless  contraction — -is  most  marked  at  the  periods  of  latent 
menstruation,  helps  to  explain  why  the  climax  should  coincide 
with  a  menstrual  period.  Why  the  tenth  menstrual  period  after 
conception  should  be  fixed  upon  can,  we  consider,  be  best 
explained  as  Bland-Sutton  explains  the  periodicity  of  menstrua- 
tion : — As  the  cardiac  cycle  is  about  one  second,  and  the  respira- 
tory cycle  about  four  seconds,  so  the  menstrual  cycle  is  about  four 
weeks  and  the  human  gestation  cycle  about  ten  lunar  months. 
It  may  also  be  explained  by  saying  that  the  human  foetus  is  so 
constituted  that  at  an  age  of  ten  months  it  no  longer  requires,  or 
is  suited  for,  intra-uterine  life,  and  that  the  various  phenomena  we 
have  recounted,  and  probably  others  as  yet  unascertained,  are  so 
co-ordinated  that  they  procure  its  expulsion  at  this  particular  time 
in  a  similar  manner  as  the  cardiac  and  respiratory  rhythms  are 
co-ordinated  to  supply  the  higher  nerve  centres  with  their  neces- 
sary proportion  of  oxygen,  etc. 

The  Stages  of  Labour. — Labour  is  divided  into  three  stages, 
which,  as  will  be  presently  seen,  are  not  mere  arbitrary  divisions, 


THE  PHENOMENA   OF  LABOUR  257 

but  are  denned  by  the  occurrence  of  special  phenomena  peculiar 
to  each  stage.  The  first  stage  comprises  the  period  during  which 
the  cervical  canal  is  dilating  in  order  to  allow  the  passage  of  the 
foetus.  It  is  hence  also  known  as  the  stage  of  dilatation.  It 
commences  with  the  onset  of  the  first  painful  contraction  of 
the  uterus,  and  ends  with  the  full  dilatation  of  the  uterine  orifice 
— an  occurrence  with  which  the  rupture  of  the  enveloping 
membranes  of  the  ovum  is  usually  synchronous.  Its  average 
length  is  in  primiparae  from  eight  to  twelve  hours,  in  multiparas 
from  six  to  eight  hours.  The  second  stage  comprises  the  period 
during  which  the  foetus  is  being  expelled  from  the  genital  passages. 
It  is  hence  also  known  as  the  stage  of  expulsion.  It  commences 
immediately  the  first  stage  is  completed,  and  ends  with  the  birth 
of  the  foetus.  Its  average  length  is  in  primiparae  from  one  to  two 
hours,  in  multiparas  from  ten  to  fifteen  minutes.  The  third  stage 
comprises  the  period  during  which  the  remainder  of  the  ovum — 
i.e.,  the  placenta  and  the  membranes — is  being  expelled.  It 
is  hence  known  as  the  placental  stage.  It  is  difficult  to  state 
what  would  be  its  average  length  if  the  process  of  expulsion  was 
left  wholly  to  the  natural  efforts,  as  this,  for  reasons  which  will 
be  presently  mentioned,  is  never  done.  It  is  usually  stated  that 
under  such  circumstances  the  placenta  would  be  expelled  in  from 
one  to  three  hours,  but  this  is  probably  too  short  an  estimate. 
If,  however,  the  usual  method  is  adopted  of  waiting  until  the 
placenta  has  been  detached  and  expelled  from  the  uterus  by  the 
natural  efforts,  and  then  expressing  it  from  the  vagina  by  pressure 
applied  over  the  supra-pubic  region,  the  average  duration  of  the 
stae:e  is  from  twelve  to  fifteen  minutes. 


THE  PHENOMENA  OF  LABOUR 

Before  entering  into  the  discussion  of  the  various  phenomena 
of  labour,  we  shall  define  certain  terms  which  will  be  frequently 
used.     These  terms  are  as  follows  : — 

Contraction. — By  this  term  is  meant  the  temporary  shortening 
of  a  muscle  fibre  which  occurs  in  response  to  a  stimulus  conveyed 
to  it  by  an  efferent  nerve. 

Retraction. — By  this  term  is  meant  the  permanent  shortening 
of  the  muscle  fibre  which  persists  after  the  contraction  has 
passed  off. 

Relaxation. — By  this  term  is  meant  the  condition  of  the  muscle 
fibre  in  the  absence  of  contraction. 

Polarity  of  the  Uterus. — By  this  term  is  meant  the  correlation 
which  exists  between  the  contractions  of  the  fundus  of  the  uterus 
and  those  of  the  cervix.  Prior  to  the  onset  of  labour,  the  muscle 
fibres  of  the  body  of  the  uterus  are  relaxed  and  those  of  the 
cervix  contracted.  After  the  onset  of  labour,  the  contraction  of 
the  muscle  fibres  of  the  body  are  simultaneous  with  a  relaxation 
of  those  of  the  cervix. 

17 


258  THE  PHYSIOLOGY  OF  LABOUR 

Uterine  Orifice. — This  term  is  used  to  denote  the  passage  which 
lies  between  the  uterine  cavity  and  the  vagina  at  any  stage  of 
labour.  The  exact  nature  of  this  passage  differs  at  the  different 
stages  of  labour.  At  one  time,  it  comprises  the  entire  cervical 
canal,  while  at  other  times  it  only  includes  portions,  which  vary 
according  to  the  number  of  children  the  woman  has  previously 
borne. 

Ths  Taking -tip  of  the  Cervix. — This  is  the  term  applied  to  the 
gradual  process  by  which  the  cervical  canal  is  made  continuous 
with,  and  so  part  of,  the  lower  uterine  segment. 

It  will  probably  help  the  student  to  understand  the  many 
undoubtedly  puzzling  and  complex  phenomena  of  labour  if  we 
first  briefly  summarise  these  phenomena  in  a  short  account  of 
the  process  of  labour.  The  extraordinary  changes,  which  take 
place  in  the  uterus  and  its  contents  during  the  twelve  to  twenty- 
four  hours  in  which  a  normal  labour  is  completed,  necessitate  the 
occurrence  of  phenomena  of  a  magnitude  greater  than  that  of  any 
other  physiological  phenomena  met  with  in  the  human  body.  At 
the  commencement  of  labour,  the  foetus  floats  in  the  liquor  amnii 
in  a  closed  sac  formed  by  the  membranes,  and  this  sac  in  turn  is 
contained  in  another  closed  sac — the  uterus.  The  connection 
between  the  sac  formed  by  the  membranes  and  the  investing 
uterus  is  but  slight,  save  at  one  point — where  the  placenta  is 
attached  to  the  uterine  wall,  and  here  large  bloodvessels  pass 
from  the  uterus  into  the  placenta.  In  order  that  the  foetus 
may  escape  from  the  sac  in  which  it  is  contained,  the  membranes 
must  rupture,  and,  in  order  that  it  may  pass  out  of  the  investing 
uterus,  the  cervical  canal  must  dilate  to  a  sufficient  size  to  allow 
it  to  pass  through.  Further,  a  powerful  force  is  necessary  in 
order  to  expel  the  foetus  from  the  uterus,  and  to  overcome  the 
resistance  which  is  offered  to  its  passage  by  the  maternal  tissues. 
Finally,  the  placenta  has  to  be  detached  and  also  expelled  from 
the  uterus,  and,  as  this  occurs,  some  mechanism  has  to  come  into 
play  which  will  obliterate  its  supplying  vessels,  and  so  prevent 
the  haemorrhage  which  would  otherwise  occur. 

These  various  changes  are  brought  about  as  follows :  — With 
the  commencement  of  labour  intermittent  contractions  of  the 
uterus  occur,  with  the  result  that  the  elastic  ovum  is  compressed. 
The  compressing  force  is  greater  above  and  at  the  sides,  and 
least  below,  and,  consequently,  the  ovum  bulges  downwards 
against  the  lower  portion  of  the  uterus.  Pari  passu  with  the  inter- 
mittent contractions,  the  polarity  of  the  uterus  shows  itself,  and 
the  fibres  of  the  cervix  relax.  Then,  as  a  result  of  the  pressure 
of  the  ovum  and  of  the  relaxation  of  the  cervical  fibres,  the 
uterine  orifice  slowly  dilates.  As  soon  as  this  dilatation  has 
reached  a  stage  sufficient  to  allow  the  head  to  pass  through,  the 
membrane  tears,  in  consequence  of  the  pressure  transmitted  to 
them  from  the  uterine  contractions,  and  of  the  loss  of  the  previous 
support  which  they  had  received  from  the  lower  pole  of  the  uterus 


THE  CONTRACTIONS  OF  THE  UTERUS  259 

and  the  walls  of  the  cervix.  The  first  stage  of  labour  is  now 
said  to  be  complete,  and  the  second  stage  commences.  The 
passage  through  which  the  foetus  is  to  pass  is  now  ready  for  it. 
The  uterine  contractions,  instead  of  merely  causing  the  dilatation 
of  the  uterine  orifice,  begin  to  expel  the  foetus  from  the  uterus, 
and,  in  obedience  to  a  natural  impulse  which  calls  on  her  to  supple- 
ment them,  the  patient  '  bears  down,'  or,  in  other  words,  she 
endeavours  by  means  of  the  accessory  muscles  of  labour — i.e., 
almost  all  the  important  voluntary  muscles  in  her  body — to 
increase  the  intraabdominal  pressure,  and  so  to  increase  the  force 
which  is  driving  the  foetus  out  of  the  uterus.  As  a  result  of  these 
forces,  the  foetus  is  driven  into  the  pelvis,  where  room  has  been  in 
part  already  made  for  it  by  the  displacement  upwards  of  certain 
of  the  pelvic  structures — notably  the  bladder.  As  the  foetus 
descends,  it  makes  more  room  for  itself  by  driving  the  greater 
part  of  the  remaining  structures  downwards  before  it.  The 
relations  of  the  bony  pelvis  also  undergo  certain  alterations, 
which  result  in  a  temporary  increase  in  various  diameters.  The 
presenting  part  then  reaches  the  vulva,  and,  passing  through  the 
latter,  is  born,  and  is  quickly  followed  by  the  rest  of  the  body. 
With  the  birth  of  the  foetus,  the  second  stage  is  completed.  The 
final  step  of  labour  consists  in  the  expulsion  of  the  remainder  of 
the  ovum — i.e.,  the  placenta  and  the  membranes.  This  process 
is  again  brought  about  by  the  contractions  of  the  uterus,  and,  as 
a  result  of  these,  the  uterus  diminishes  so  much  in  size  that  the 
placenta  is  detached,  and  is  expelled  from  the  uterine  cavity, 
while  as  a  result,  not  only  of  the  contraction  of  the  uterus,  but 
still  more  of  its  retraction,  the  bloodvessels  which  run  into  the 
placenta  are  so  compressed  and  kinked  that  any  further  haemor- 
rhage through  them  is  prevented. 

We  thus  see  that  the  principal  phenomenon  of  labour,  to  which 
almost  all  the  other  phenomena  are  due,  is  the  occurrence  of 
uterine  contractions,  helped  by  the  contractions  of  the  accessory 
muscles  of  labour. 

The  Contractions  of  the  Uterus. — The  nature  of  the  contractions 
of  the  uterus  is  so  intimately  connected  with  the  anatomy  of  the 
muscle  of  that  organ,  that  we  consider  it  necessary  to  recapitulate 
a  little  of  what  has  gone  before.  From  an  obstetrical  point  of 
view,  the  uterus  is  composed  of  three  parts  or  zones  (v.  Fig.  143)  :— 

(1)  An  Upper  Zone — the  Upper,  or  the  Contractile,  Uterine  Segment. 
— This  zone  contains  that  portion  of  the  uterine  muscle  whose 
contractions  effect  the  expulsion  of  the  foetus.  It  is  composed  of 
fibres  which  run  in  all  directions,  and  is  completely  covered  by 
firmly  attached  peritoneum. 

(2)  A  Lower  Zone — the  Lower,  or  Non-contractile,  Uterine  Segment. 
— This  zone  lies  between  the  upper  uterine  segment  and  the 
inner  os.  The  junction  between  the  upper  and  lower  segments  is 
termed  the  'retraction  ring,'  and  corresponds  to  the  place  at 
which  the  structure  and  arrangement  of  the  muscle  fibres  peculiar 

17 — 2 


260 


THE  PHYSIOLOGY  OF  LABOUR 


to  the  upper  segment  ends.  This  takes  place  at  a  level  coincident 
with  the  line  of  reflexion  of  the  peritoneum  off  the  anterior  face  of 
the  uterus,  and  also  to  the  entry  of  the  uterine  artery.  The 
muscle  fibres  of  the  lower  zone  are  very  loosely  connected  with 
one  another,  and  run  some  circularly  and  others  longitudinally. 
The  circular  fibres,  in  accordance  with  the  property  of  so-called 
polarity  of  the  uterus,  relax  pari  passu  with  the  contractions  of  the 
upper  uterine  segment,  while  the  longitudinal  bands,  by  their 
contractions,  draw  the  cervix  upwards  over  the  advancing  ovum. 
There  is  no  peritoneal  covering  in  front  of  this  segment,  while 


Fig.  143. — Diagram  showing  the  Approximate  Position  of  the  Retraction 
Ring  (RR)  at  the  Commencement  of  Labour. 

Above  RR  is  the  upper  uterine  segment,  below  RR  the  lower  uterine  segment. 
oi,  Os  internum  ;  oe,  os  externum. 


posteriorly  the  peritoneal  attachment  is  loose,  thus  contrasting 
markedly  with  the  covering  of  the  upper  segment. 

(3)  The  Cervix. — This  zone  comprises  that  portion  of  the  uterus 
which  lies  below  the  inner  os.  It  also  contains  circular  fibres, 
which  act  similarly  to  those  found  in  the  lower  segment. 

Accordingly,  we  see  that  the  uterus  is  a  most  complexly  formed 
hollow  muscle.  During  pregnancy,  it  is  in  a  condition  of  relaxa- 
tion, save  so  far  as  the  circular  fibres  of  the  cervix  are  concerned, 
and  they  are  in  tonic  contraction.  As  soon  as  labour  commences, 
the  condition  is  reversed.  The  fibres  of  the  upper  segment  and 
the  longitudinal  fibres  of  the  lower  segment  contract,  and  the 
circular  fibres  of  the  lower  segment  and  of  the  cervix  simul- 
taneously relax. 

The  contractions  of  the  uterus  possess  four  characteristics  : — ■ 
they  are  intermittent,  peristaltic,  involuntary,  and  painful. 


THE  CONTRACTIONS  OF  THE  UTERUS  261 

At  the  commencement  of  labour,  contractions  occur  only  at 
long  intervals,  a  period  of  perhaps  an  hour  elapsing  between 
each.  As  the  first  stage  proceeds,  they  become  more  frequent, 
and  occur  on  an  average  every  twenty  minutes  during  the  taking- 
up  of  the  cervix,  and  every  two  to  three  minutes  during  the 
dilatation  of  the  uterine  orifice  (Ribemont-Dessaignes).  During 
the  second  stage,  they  occur  at  first  every  five  to  ten  minutes, 
and  increase  in  frequency,  until  during  the  birth  of  the  foetus  they 
are  almost  continuous.  After  delivery,  the  contractions,  as  a  rule, 
cease  for  from  five  to  fifteen  minutes,  and  then  again  recur  every 
five  minutes  or  so,  until  the  placenta  has  been  detached  and 
expelled  from  the  uterus.  The  duration  of  a  contraction  varies 
in  accordance  with  the  stage  of  labour.  At  the  commencement 
of  labour  a  contraction  lasts  a  few  seconds,  and  gradually 
increases  in  duration  until  during  the  second  stage  it  lasts  from 
thirty  to  ninety  seconds. 

It  is  probable  that  the  uterine  contractions  are  peristaltic  in 
character,  but  this  has  not  been  definitely  determined.  Kehrer 
has  observed  a  peristaltic  character  in  the  contractions  of  the 
uterus  in  animals,  and  Von  Herff  in  women  during  Csesarean 
section.  On  the  other  hand,  many  observers  deny  this,  and 
even  among  those  who  admit  it,  the  direction  in  which  the 
wave  travels  has  not  been  agreed  upon.  According  to  some, 
it  commences  at  the  cervix  and  passes  upwards,  but  the  more 
general  opinion  is  that  it  commences  in  the  region  of  the  tubes 
and  passes  downwards  towards  the  cervix.  The  time  occupied  by 
the  peristaltic  wave  in  spreading  over  the  uterus,  in  proportion  to 
the  total  duration  of  the  contraction,  is  small.  The  pain,  as  a 
whole,  lasts  from  sixty  to  ninety  seconds,  and  the  peristaltic  action 
from  twenty  to  thirty  seconds  (Schatz). 

The  involuntary  character  of  the  contraction  is  common  to  all 
unstriped  muscle  fibre.  The  occurrence  of  contractions  is,  how- 
ever, affected  by  nervous  influences,  such  as  may  arise  from  the 
presence  of  a  stranger  in  the  room,  dread  of  pain,  and  such-like 
causes. 

The  painful  nature  of  uterine  contractions — a  fact  to  which  the 
term  '  pain  '  as  applied  to  these  contractions  owes  its  origin — is 
one  of  their  most  marked  characteristics.  The  pain  occurs  at  the 
height  of  the  contraction,  which  commences  and  ends  painlessly. 
Its  site,  cause,  and  nature  vary  according  to  the  period  of  labour. 
The  preliminary  pains — dolores  presagientes — which  usually  usher 
in  labour  are  very  irregular  in  their  occurrence,  and  are  felt  over 
the  abdomen  generally.  They  are  not  severe  in  character,  and 
are  probably  due  to  the  increased  force  of  the  hitherto  painless 
uterine  contractions  and  to  commencing  dilatation  of  the  cervix. 
During  the  first  stage  of  labour,  the  pain  is  principally  referred  to 
the  region  of  the  sacrum,  and  to  a  slighter  extent  to  the  sides  of 
the  uterus.  It  is  chiefly  due  to  the  stretching  of  the  cervix,  and 
to  a  less  extent  to  the  contractions  of  the  uterus,  and  is  of  a  dull, 


262  THE  PHYSIOLOGY  OF  LABOUR 

and  aching  character.  With  the  advent  of  the  second  stage, 
and  the  increase  in  the  strength  of  the  uterine  contractions,  the 
pain  becomes  more  severe.  It  is  felt  in  the  uterus,  due  to  the 
compression  of  nerves  situated  in  the  uterine  wall ;  in  the  sacrum 
and  pelvis  generally,  due  to  the  stretching  of  the  vagina  and 
perinseum  ;  and  in  the  thighs  and  legs,  due  to  pressure  upon  the 
sacral  plexus.  During  this  stage,  the  pain  grows  in  severity, 
and  reaches  a  climax  during  the  passage  of  the  head  over  the 
perinaeum,  when  it  is  described  as  being  of  a  violent  tearing  or 
cutting  character.  During  the  third  stage,  the  pains  are  felt 
principally  in  the  uterus,  and  are  probably  due  to  the  compres- 
sion of  the  uterine  nerves.    As  a  rule,  they  are  not  severe. 

Various  terms  have  been  used  from  time  to  time  to  imply  the 
character  of  the  pains  which  occur  at  different  periods  of  labour. 
The  preliminary  pains  are  termed  false  pains,  dolores  presagientes, 
or  premonitory  pains.  The  pains  which  occur  during  the  first 
stage  are  termed  dolores  prceparantes,  or  preparatory  pains.  The 
earlier  pains  of  the  second  stage  are  termed  expulsive  pains,  or 
dolores  ad  partum ;  while  the  final  pains  of  this  stage  are  termed 
dolores  conquass antes,  or  shivering  pains,  owing  to  the  quivering  of 
the  lower  limbs  which  sometimes  accompany  them.  The  pains 
which  occur  during  the  third  stage  are  known  as  the  after-birth 
pains,  or  dolores  ad  secundines.  Finally,  the  pains  which  occur 
during  the  days  subsequent  to  delivery  are  termed  after-pains, 
or  dolores  post-partum. 

Various  attempts  have  been  made  to  determine  the  strength 
of  a  uterine  contraction — i.e.,  the  compression-force  it  exerts  on 
the  unruptured  bag  of  membranes,  or  with  which  it  drives  the 
foetus  downwards,  and  the  most  contradictory  results  have  been 
obtained.  Schatz  determined  that  the  intra-uterine  pressure,  as 
measured  in  the  region  of  the  internal  os,  varied  from  17  to 
55  pounds.  Ribemont-Dessaignes  ascertained  that  a  force  of 
from  10,660  to  11,179  grammes  (23 "5  to  24-6  pounds)  was  required 
to  rupture  the  foetal  membranes.  According  to  Matthews  Duncan, 
the  force  required  varies  from  41  to  36  pounds,*  with  an  average 
force  of  15  pounds.  While  Leaman,  by  means  of  a  special 
instrument,  found  that  when  the  force  with  which  the  head  was 
advancing  through  the  pelvis  did  not  exceed  two  pounds,  the  foetus 
subsequently  required  to  be  extracted  by  means  of  the  forceps. 
These  figures  possess  no  practical  importance,  and,  indeed,  it  is 
difficult  to  see  how  a  means  of  measuring  the  force  of  the  uterine 
contractions  which  would  give  results  of  practical  importance 
could  be  devised,  or  which  would  measure  anything  save  the 
difference  between  the  strength  of  the  contractions  of  the  uterus 
and  the  resistance  to  the  advance  of  the  soft  parts.  Clinically,  it 
would  appear  as  if  the  force  of  the  contraction  depended  upon 
the  resistance  offered  to  the  descent  of  the  presenting  part,  and 

*  'Researches  in  Obstetrics,'  p.  299. 


Plate   I. — Mesial  Sagittal   Section   of   a   Primipara   who   died   at 
Full  Term,  but  before  the  Commencement  of  Labour. 

Note  the  condition  of  the  cervix  and  the  attitude  of  the  fetus.     (Waldeyer.) 

[To face /.  263. 

I 


THE  CONTRACTIONS  OF  THE  UTERUS  263 

that  it  varied  considerably  throughout  labour.     Both  these  prob- 
abilities have,  however,  been  denied  by  various  authorities. 

The  round  ligaments  contract  synchronously  with  the  uterine 
muscle,  of  which  they  must  be  regarded  as  an  extension.  Their 
effect  is  to  draw  the  uterus  downwards,  and  so  to  counteract  the 
tendency  of  the  fundus  to  rise  upwards. 

The  Contractions  of  the  Accessory  Muscles  of  Labour. — The 
accessory  muscles,  which  come  to  the  aid  of  the  uterine  muscle 
during  the  period  of  expulsion,  are  composed  of  almost  all  the 
important  voluntary  muscles  of  the  body.  Primarily,  they  con- 
sist of  those  muscles  which  can  aid  in  diminishing  the  size  of  the 
abdominal  cavity  ;  while,  secondarily,  they  consist  of  the  muscles 
of  the  limbs,  which  assist  in  fixing  the  thorax  and  pelvis,  and  so 
furnish  the  other  muscles  with  a  point  d'apptti.  It  is  unnecessary 
to  enumerate  the  muscles  which  are  included  in  the  first  group. 
Speaking  generally,  they  consist  of  the  muscles  which  aid  in 
closing  the  glottis,  of  the  diaphragm,  of  the  other  muscles  of 
expiration,  and  of  the  muscles  of  the  abdominal  wall.  The  effect 
of  the  contraction  of  the  auxiliary  muscles  is  to  cause  a  uniform 
pressure  over  the  body  of  the  uterus,  and  so  both  to  expel  the 
uterine  contents  and  also  to  drive  the  uterus  as  a  whole  down- 
wards. The  latter  action  is  of  importance,  inasmuch  as  it  tends 
to  prevent  the  excessive  thinning  of  the  lower  uterine  segment 
which  might  occur  if  the  upper  segment  was  free  to  rise  upwards, 
as  its  tendency  is,  in  the  abdominal  cavity. 

The  Effect  of  the  Uterine  Contractions  on  the  Uterus. — The 
uterine  contractions  must  be  studied  in  relation  to  their  effect 
on  the  uterus,  the  pelvic  contents  and  perinaeum,  the  pelvic 
bones,  the  ovum,  and  the  maternal  system  generally.  The 
first  effect  of  the  contractions  on  the  uterus  is  to  cause  a  con- 
siderable temporary  diminution  in  size  in  the  cavity  of  the  uterus 
due  to  contraction  of  the  muscle  fibres,  and  a  slight,  but  progres- 
sive and  permanent,  diminution,  due  to  retraction  of  the  fibres. 
During  a  contraction,  the  longitudinal  diameter  of  the  uterus  is 
increased,  owing  to  the  expansion  of  the  lower  uterine  segment.  At 
the  same  time,  the  transverse  diameters  are  diminished,  and  the 
wall  is  increased  in  thickness,  the  total  result  being  a  diminution 
in  the  size  of  the  cavity.  As  a  result  of  this  diminution,  the 
ovum  is  compressed,  and  so  is  compelled  to  find  room  for  itself 
by  bulging  in  whatever  direction  the  resistance  offered  to  it  is 
least.  This  area  of  least  resistance  is  found  in  the  neighbour- 
hood of  the  os  internum,  a  fact  which  is  accounted  for  mainly  by 
the  anatomical  and  physiological  peculiarities  of  the  lower  uterine 
segment.  As  will  be  remembered,  the  muscle  fibres  are  differ- 
ently arranged,  and  are  fewer  at  this  part  of  the  uterus  than  they 
are  in  the  remainder  of  the  body ;  and,  further,  as  a  consequence 
of  uterine  polarity,  they  relax  pari  passu  with  the  contractions  of 
the  fundus.  To  a  slight  extent,  two  other  factors  also  assist  in 
making  the  lower  uterine  segment  the  area  of  least  resistance. 


264 


THE  PHYSIOLOGY  OF  LABOUR 


These  are  the  pressure  of  the  abdominal  contents  and  wall  upon 
the  remainder  of  the  uterine  body,  and  the  influence  of  gravity 
on  the  ovum  while  the  patient  is  in  the  erect  posture.     The  con- 


Fig.  144. — The  Cervix  in  a  Primipara  at  the  Commencement  of  Labour. 
UC,  Uterine  cavity ;  01,  os  internum  ;  CC,  cervical  cavity  ;  OE,  os  externum. 

tinuance  of  uterine  contractions  leads  to  the  following  important 
changes  : — 

(1)  The  taking  up  of  the  cervix. 

(2)  Dilatation  of  the  uterine  orifice. 

(3)  Expansion  of  the  lower  uterine  segment. 

(4)  Diminution  in  size  of  the  upper  uterine  segment. 

(1)  The  Taking-up  of  the  Cervix. —  The  taking-up  of  the  cervical 
canal  into  the  lower  uterine  segment  is  a  process  which  differs  in 
detail  and  in  degree  in  the  case  of  primiparae  and  multipara?.     In 


Fig.   145. — The  Taking-up  of  the  Cervix  in  a  Primipara. 

The  upper  portion  has  been  taken  up.     UC,  Uterine  cavity  ;  OI,  os  internum 
CC,  cervical  cavity  ;   OE,  os  externum. 


both  cases,  the  mechanism  by  which  it  is  accomplished  is  the 
same,  and  consists  in  the  softening  which  has  been  progressively 
taking  place  in  the  cervical  tissues  during  pregnancy ;  in  the  con- 
tractions of  the  longitudinal  fibres  of  the  uterus  which  draw  up 


THE  CERVIX  DURING  LABOUR 


265 


the  cervix  over  the  advancing  ovum  ;  and  in  the  contractions  of 
the  upper  uterine  segment  which  drive  the  ovum  downwards. 
In  primiparae,  at  the  commencement  of  labour,  the  cervix  pre- 


U.C, 


Fig.   146. — The  Taking-up  of  the  Cervix  in  a  Primipara. 

The  taking-up  is  almost  complete,  but  the  uterine  orifice  is  still  undilated. 
UC,  Uterine  cavity;  OI,  os  internum;  CC,  cervical  cavity;  OE,  os 
externum. 

sents  more  or  less  its  characteristic  outline  and  length,  and  both 
the  internal  and  external  os  are  closed.  The  process  of  taking- 
up   closely   resembles  the  effect  which   would   be   produced    by 


u.c. 


Fig.    147. — The  Taking-up  of  the  Cervix  in  a  Primipara. 

The  taking-up  is  complete,  and  the  uterine  orifice  is  fully  dilated.     UC,  Uterine 
cavity  ;  OI,  os  internum  ;  CC,  cervical  cavity  ;  OE,  os  externum. 


pushing  a  cone  through  the  cervical  canal  from  above  down- 
wards (v.  Figs.  144-147).  First,  the  internal  os  dilates,  and  its 
outline  is  practically  lost.  Then  the  supravaginal  portion  of  the 
cervical  canal  dilates  in   the  same  manner,  and   then  the  infra- 


266 


THE  PHYSIOLOGY  OF  LABOUR 


vaginal  portion.  The  taking-up  of  the  cervix  is  now  complete, 
the  uterine  and  cervical  cavities  are  continuous  with  one  another, 
and  the  uterine  orifice  is  alone  enclosed  by  the  thinned-out  edges 
of  the  external  os. 

In  multiparae,  on  the  other  hand,  the  cervix  has  at  the  com- 
mencement of  labour  lost  its  original  contour  to  a  varying  extent. 


U.C. 


-  0.1 


Fig.  148. — The  Cervix  in  a  Multipara  at  the  Commencement  of  Labour. 
UC,  Uterine  cavity ;  OI,  os  internum  ;  CC,  cervical  cavity;  OE.os  externum. 

The  external  os  is  already  patulous,  and  will  admit  one  or  two 
fingers,  so  that  whereas  in  primiparae  the  upward  passage  of  the 
examining  finger  is  checked  by  the  resistance  of  the  external  os  ; 
in  multiparae  it  is  checked  by  the  resistance  offered  by  the  supra- 
vaginal portion  of  the  cervix,  or  even  by  the  internal  os.     This 


Fig.   149.  — The  Taking-up  of  the  Cervix  in  a  Multipara. 

The  upper  portion  has  been  taken  up.     UC,  Uterine  cavity  ;  OI,  os  internum ; 
CC,  cervical  cavity;  OE,  os  externum. 


is  probably  due  to  the  increased  degree  of  softening  which  is 
present  in  these  cases,  and  also  to  the  effect  of  former  lacerations 
and  consequent  ectropion.  In  such  cases,  the  taking  up  of  the 
cervix  is  not  so  complete  as  in  primiparae  (v.  Figs.  148-150). 
The  first  step  consists  in  the  dilatation  of  the  internal  os,  followed 


Plate  II. — Mesial   Sagittal   Section  of  a  Primipara  who  died  during 
the  First  Stage. 

The  transverse  position  of  the  head  is  accounted  for  by  the  fact  that  the  pelvis 
measured  only  3*6  inches  in  the  true  conjugate.  Note  the  taking  up  of  the 
cervix.     (Saexinger.) 

[  To  face  p.  267. 


THE  CERVIX  DURING  LABOUR 


267 


by  the  dilatation  of  the  supravaginal  portion  of  the  cervical 
canal.  The  process  of  taking  -  up  is  now  complete,  and  the 
uterine  orifice  is  enclosed  by  the  greater  part  of  the  infravaginal 
portion  of  the  cervix.  Consequently,  whereas  in  primipara^  the 
uterine  orifice  is  encircled  by  the  thin,  almost  paper-like,  edges 
of  the  os  externum,  in  multiparas  it  is  encircled  by  blunt,  com- 
paratively thick  edges,  formed  by  the  lower  half  of  the  cervical 
tissues. 

(2)  The  Dilatation  of  the  Uterine  Orifice. — The  dilatation  of  the 
uterine  orifice  is  brought  about  by  the  expansile  pressure  exerted 
on  its  edges  by  the  wall  of  the  ovum,  and  by  the  contractions  of 
the  longitudinal  bands  of  muscle  fibre,  which  draw  the  remaining 
portion  of  the  cervix  upwards.     As  soon  as  this  upward  retrac- 


Fig.   150. — The  Taking-up  of  the  Cervix  in  a  Multipara. 

The  taking-up  is  almost  complete,  and  the  uterine  orifice  is  almost  completely 
dilated.  UC,  Uterine  cavity;  OI,  os  internum;  CC,  cervical  cavity; 
OE,  os  externum. 


tion  of  the  cervix  is  so  complete  that  almost  all  trace  of  cervical 
projection  has  disappeared,  dilatation  is  complete,  and  the  utero- 
cervical  and  vaginal  cavities  are  continuous.  During  the  dilata- 
tion of  the  cervix,  the  cervical  glands  pour  forth  large  quantities 
of  mucus,  which  materially  facilitates  the  expulsion  of  the  foetus 
by  its  lubricating  effect  on  the  walls  of  the  genital  canal. 

(3)  The  Expansion  of  the  Lower  Uterine  Segment. — The  changes 
which  take  place  in  the  lower  uterine  segment  during  labour, 
consequent  on  the  occurrence  of  uterine  contractions,  are  not 
only  amongst  the  most  interesting  phenomena  of  labour,  but  are 
of  the  greatest  practical  importance.  As  we  have  seen,  at  the 
commencement  of  labour  the  lower  uterine  segment  comprises 
the  zone  between  the  retraction  ring  and  the  os  internum,  and  is 


268  THE  PHYSIOLOGY  OF  LABOUR 

about  i\  inches  in  depth.*  When  the  takmg-up  of  the  cervix  is 
complete,  the  lower  uterine  segment  is  increased  in  size  by  the 
added  portion  of  the  cervical  tissues.  Above  the  retraction  ring, 
the  uterine  muscle  contracts  and  retracts  during  labour.  Below 
it,  the  muscle  relaxes,  with  the  exception  of  the  longitudinal 
bands  which  draw  the  cervix  upwards.  With  each  contraction 
of  the  uterus,  the  capacity  of  the  upper  segment  diminishes, 
while  the  capacity  of  the  lower  segment  increases  owing  to  the 
descent  of  the  ovum.  The  combined  effect  of  these  changes  in 
the  upper  and  lower  segments  is  to  produce  an  actual  elongation 
of  the  uterus,  which  persists  even  after  the  head  has  passed  com- 
pletely into  the  pelvis,  so  that,  according  to  Fothergill,  the  average 
height  of  the  fundus  above  the  pubis  is  95  inches  during  the  first 
stage,  and  9*8  inches  at  the  end  of  the  second  stage.  At  first,  this 
diminution  in  size  of  the  upper  segment  occurs  and  passes  off 
with  each  contraction  ;  but,  as  labour  continues  and  retraction 
becomes  more  marked,  each  contraction  leaves  the  cavity  of  the 
upper  segment  slightly  smaller  than  it  was  before.  It  is  obvious 
that,  so  long  as  the  foetus  is  completely  contained  in  the  uterus, 
this  gradual  diminution  in  size  of  the  upper  segment  must  be 
accompanied  by  a  corresponding  increase  in  size  in  the  lower 
segment.  This,  under  normal  circumstances,  is  obtained  by  the 
taking-up  of  the  cervix,  and  as  soon  as  this  process  is  complete 
and  the  uterine  orifice  dilated,  the  advance  of  the  foetus  renders 
further  expansion  unnecessary.  If,  however,  there  is  any  obstacle 
to  the  birth  of  the  foetus,  then  the  progressive  retraction  of  the 
upper  segment  necessitates  an  increased  amount  of  expansion  of 
the  lower  segment.  The  greater  this  obstacle  is,  and,  conse- 
quently, the  longer  labour  continues,  the  greater  is  the  increase 
in  size  of  the  lower  segment,  until,  finally,  if  labour  continues 
sufficiently  long,  the  lower  uterine  segment  becomes  so  thinned  by 
expansion  that  it  yields  to  the  pressure  of  the  foetus,  and  a  rupture 
of  the  uterus  occurs  (v.  Fig.  151).  The  junction  between  the  upper 
and  lower  segments  is  known  variously  as  the  retraction  ring,  the 
contraction  ring,  and  as  Bandl's  ring.  The  last  term  should  not 
be  applied  to  it,  as  it  is  definitely  associated  with  the  theory  of 
Bandl  regarding  the  formation  of  the  lower  segment  and  the 
situation  of  the  ring.  We  agree  with  Barbour  that  the  term 
retraction  ring  is  the  most  suitable,  inasmuch  as  the  ring  is  the 
result  of  the  progressive  and  permanent  occurrence  of  retraction, 
and  not  of  the  temporary  occurrence  of  contraction.  In  conse- 
quence of  the  diminution  in  size  of  the  upper  segment,  the  ring 
progressively  rises  towards  the  fundus  of  the  uterus.  In  normal 
cases  the  ring  is  not  apparent,  but  in  cases  of  prolonged  labour 
the  retraction  ring  may  be  actually  felt  through  the  abdominal 
walls  as  a  depression  running  obliquely  across  the  uterus,  at 
first  a  little  above  the  symphysis,  and,  finally,  perhaps  in  the 
region  of  the  umbilicus.     Accordingly,  we  see  that  the  position 

*  Schroeder-Stratz  :  Frozen  section. 


THE  FUNCTIONS  OF  THE  LOWER   UTERINE  SEGMENT     269 

of  the  retraction  ring,  if  it  can  be  ascertained,  affords  a  positive 
indication  of  the  effect  of  the  contractions  on  the  uterine  muscle 
fibre. 

The  functions  of  the  lower  uterine  segment  are  two  in  number. 
In  the  first  place,  as  will  be  readily  understood,  but  for  its 
existence,  the  uterine  contractions  could  not  bring  about  the 
expulsion  of  the  foetus.  If  the  entire  uterus  was  composed  of  an 
identical  arrangement  of  muscle  fibre,  the  contraction  of  the  latter 
would  merely  tend  to  compress  the  ovum.  When,  however,  the 
lower  segment  of  the  uterus  contains  fibres  which  apparently  act 


Fig.    151. — Diagrammatic  Section  of  the  Uterus  after  Prolonged 
Labour,  to  show  the  Position  of  the  Retraction  Ring. 

RR,  Retraction  ring;  OI,  internal  os  ;   OE,  external  os. 


in  opposition  to  the  fibres  of  the  upper  segment,  and  so  provide  a 
place  into  which  the  contractions  of  the  latter  can  drive  the  ovum, 
its  expulsion  from  the  uterus  is  possible.  Consequently,  the  first 
function  of  the  lower  segment  is  to  facilitate  the  expulsion  of  the 
foetus.  The  second  function  of  the  lower  uterine  segment  consists 
in  forming  a  ring,  which  prevents  the  descent  of  the  presenting  part 
until  the  uterine  orifice  is  sufficiently  dilated  to  allow  the  latter 
to  pass.  Into  this  ring,  the  presenting  head  is  driven  by  each 
contraction  in  such  a  manner  that  the  two  together  act  as  does 
a  ball-valve.  As  has  been  already  explained,  this  action  is  very 
important.     Prior  to  each  contraction  of  the  uterus,  the  liquor 


270 


THE  PHYSIOLOGY  OF  LABOUR 


aranii  which  surrounds  the  body  of  the  fcetus  is  in  free  inter- 
communication with  the  liquor  amnii  which  lies  in  front  of  the 
head.  If  this  intercommunication  was  to  persist  during  a  con- 
traction, the  result  would  be  that  a  great  quantity  of  liquor  amnii 
would  be  forced  in  front  of  the  head,  and  that,  in  consequence, 
the  tension  on  the  membranes  lying  over  the  dilating  cervix  wrould 
be  so  great  that  they  would  rupture  long  before  the  uterine  orifice 
was  dilated.  Instead  of  this,  however,  the  contraction  drives  the 
head  so  firmly  into  the  embrace  of  the  lower  segment  that  all 


F  G  H 

Fig.  152. — The  Muscles  of  the  Pelvic  Floor  shown  at  the  Commence- 
ment of  Dilatation  by  the  Fcetal  Head. 

A,  Erector  clitoridis ;  B,  constrictor  vaginae;  C,  vagina;  D,  urethra  E,  cli- 
toris; F,  transversus  perinaei ;  G,  levator  ani;  H,  sphincter  ani;  K,  central 
point  of  perinaeum.     (Bumm.) 


communication  between  the  hind-waters  and  the  fore-waters  is 
temporarily  shut  off,  and  that,  consequently,  the  tension  on  the 
membranes  is  only  increased  in  proportion  as  the  head  descends. 
This  ball-valve  action  is  further  of  importance  at  the  time  the 
membranes  rupture,  inasmuch  as  it  prevents  the  escape  of  the 
liquor  amnii  which  surrounds  the  body  of  the  fcetus.  But  for  it, 
as  soon  as  the  membranes  ruptured,  the  liquor  amnii  would  all 
flow  away  with,  perhaps,  sufficient  force  to  carry  with  it  the 
cord.  This  function  of  the  lower  segment  is  not  accepted  by  all 
authorities.  On  the  contrary,  many,  notably  Galabin*  and  Dakin,f 
consider  that  so  far  from  the  presenting  head  accurately  fitting 

*  '  A  Manual  of  Midwifery,'  p.  165. 
f  'A  Handbook  of  Midwifery,'  p.  106. 


Plate    III. — Mesial   Sagittal    Section  of  a  Primipara  who   died   during 
the  Second  Stage,  but  before  the  Membranes  ruptured. 


Note  the  complete  obliteration  of  the  cervix. 


(Braun.) 

[To  face  p.  271. 


CHANGES  IN  THE  PELVIS  DURING  LABOUR  271 

the  lower  segment,  it  would  be  a  misfortune  if  it  was  to  do  so. 
With  this  view,  as  also  with  the  opinion  that  the  head  does  not 
plug  the  lower  segment  under  normal  circumstances,  we  cannot 
agree.  Clinically,  it  is  a  matter  of  common  experience  that  if 
any  factor  prevents  the  descent  of  the  presenting  part  into  the 
lower  segment,  or  if  the  presenting  part  is  not  of  such  a  shape 
that  it  can  plug  the  lower  segment,  the  membranes  protrude 
through  the  cervix  in  a  conical  tumour,  in  some  cases  to  such  an 
extent  as  to  fill  the  entire  vagina,  and  their  early  rupture  is  the 
rule.  Further,  in  normal  cases  the  increase  in  the  quantity  of 
liquor  amnii  in  front  of  the  presenting  head  during  a  contraction 
is  not  so  great  as  would  be  the  case  if  free  communication 
existed  between  the  fore-  and  bind-waters. 

(4)  Diminution  in  the  Size  of  the  Upper  Uterine  Segment. — As  we 
have  already  seen,  contraction  of  the  uterine  muscle  during  labour 
results  in  a  temporary  diminution  in  size  of  the  upper  segment 
and  the  consequent  expulsion  of  the  foetus,  while  retraction  results 
in  a  permanent  and  progressive  diminution,  and  the  consequent 
adaptation  of  the  uterus  to  its  lessened  contents.  Accordingly, 
during  the  first  and  second  stage,  the  uterine  cavity  becomes 
smaller  as  the  foetus  is  expelled,  and  its  walls  at  the  same  time 
increase  in  thickness ;  during  the  third  stage,  the  cavity  is  only 
sufficiently  large  to  contain  the  placenta  ;  while,  subsequent  to 
the  expulsion  of  the  latter,  the  cavity  is  only  a  potential  one. 
The  thickness  of  the  uterine  wall  at  the  commencement  of 
labour,  as  ascertained  from  frozen  sections,  is  about  7  millimetres 
(|  inch).  At  the  end  of  the  second  stage,  it  is  found  to  be  from 
9  to  18  millimetres  (f  to  f  inch).  The  effect  of  this  diminution 
in  the  size  of  the  uterine  cavity  on  the  placenta  will  be  subse- 
quently discussed.  Its  effect  on  the  uterine  vessels  is  obvious. 
During  the  period  of  a  contraction  the  uterine  vessels  are  tem- 
porarily compressed  and  twisted,  and  as  a  result  of  retraction 
their  permanent  obliteration  is  procured.  By  this  means,  the 
haemorrhage  which  would  otherwise  result  from  the  opening  of 
large  vessels  is  prevented,  the  vessels  being  controlled,  as  it 
were,  '  by  thousands  of  living  ligatures  '  (Pinard).  During  the 
process  of  detachment  of  the  placenta,  however — that  is,  before 
retraction  is  complete — a  certain  loss  of  blood  normally  occurs. 
The  average  amount  is  said  to  be  four  ounces  before  the 
expulsion  of  the  placenta,  and  six  ounces  with  the  placenta  and 
membranes  (Dakin). 

The  Effect  of  the  Uterine  Contractions  on  the  Pelvic  Contents. — - 
The  manner  in  which  the  pelvic  cavity  is  temporarily  emptied  of  its 
contents  in  order  to  afford  room  for  the  passage  through  it  of  the 
foetal  head  constitutes  one  of  the  most  interesting  phenomena  of 
labour.  If  we  contrast  a  sagittal  section  of  the  pelvis  in  the 
non-impregnated  female  with  Braun's  section  of  a  patient  who 
died  during  the  second  stage,  we  shall  see  what  a  complete  clear- 
ance of  the  normal  pelvic  contents  takes  place.     The  contents  of 


272 


THE  PHYSIOLOGY  OF  LABOUR 


the  pelvis,  as  seen  in  antero-posterior  section,  are  so  arranged  as 
to  form  two  triangles  separated  from  one  another  by  the  vaginal 
slit — an  anterior  and  superior  triangle,  and  a  posterior  and  inferior 
triangle.  The  anterior  triangle  has  its  base  on  a  line  drawn 
through  the  pubis,  and  continued  to  the  anterior  commissure  of 
the  vagina,  and  its  apex  at  the  anterior  lip  of  the  cervix.  The 
posterior  triangle  has  its  base  on  the  last  three  pieces  of  the 
sacrum  and  on  the  coccyx,  and  its  apex  at  the  posterior  com- 
missure of  the  vagina.  The  structures  contained  in  the  anterior 
triangle  are  intimately  connected  with  the  cervical  tissues,  while 


Fig.  153. 


-The  Muscles  of  the  Pelvic  Floor,  shown  at  the  Moment  of 
Complete  Dilatation  by  the  Fcetal  Head. 


A,  Pubo-coccygeus ;  D,  obturato-coccygeus ;  E,  ischio-coccygeus  (A,  D,  and  E 
are  placed  on  the  different  parts  of  the  levator  ani  muscle) ;  B,  sphincter 
ani ;  C,  vagina.     (Bumm.) 


the  structures  contained  in  the  posterior  triangle  are  quite  inde- 
pendent of  any  uterine  connections.  To  these  relationships  are 
due  the  disposition  of  the  pelvic  contents  during  labour.  As 
the  cervix  is  drawn  upwards  by  the  contraction  of  the  longi- 
tudinal bands  of  muscle  fibre,  it  draws  up  with  it  the  greater  part 
of  the  structures  in  the  anterior  triangle.  In  this  manner,  the 
bladder,  which  at  the  commencement  of  labour  lay,  while  empty, 
entirely  below  the  pelvic  brim,  is  drawn  up  out  of  the  pelvis  into 
the  abdomen.  The  structures  in  the  anterior  triangle,  which  are 
not  connected  with  the  cervix — viz.,  the  lower  third  of  the  vaginal 
wall  and  the  urethra — are  pushed  downwards  in    front    of   the 


uc 


RR 


Plate  IV. — Braun's  Section,  after  the  Removal  of  the  Fcetus. 

P,  Placenta  ;  UC,  uterine  cavity  ;  RR,  retraction  ring  ;  OI,  os  internum  ;  OE,  os 
externum;  V,  vagina;  B,  bladder;  U,  urethra;  VI,  vulva;  A,  anus. 

[To  face  p.  272. 


CHANGES  IN  THE  PERIN/EUM  DURING  LABOUR 


273 


presenting  part.  As  the  presenting  part  descends,  it  pushes  before 
it  the  posterior  triangle,  which,  as  we  have  mentioned,  is  un- 
affected by  the  retraction  of  the  cervix.  In  this  manner,  the 
lower  portion  of  the  rectum,  the  perinaeal  body,  and  the  muscles 
of  the  pelvic  floor,  which  lie  posterior  to  the  vagina,  are  pushed 
downwards  by  the  presenting  part  (v.  Figs.  152,  153).  The  dis- 
placement of  these  two  triangles  may  be  described,  with  Galabin, 
as  resembling  the  opening  of  double  doors  which  swing  in  opposite 
directions.  As  a  result,  the  pelvis  is  practically  empty  save  for  the 
intermediate  portion  of  the  urethra,  the  rectum,  and  the  vaginal 


Fig.  154. — The  Genital  Canal  in  a  Condition  of  Complete  Dilatation, 
as  seen  after  Mesial  Sagittal  Section. 

A,  Anus;  B,  perinseum.     (Bumm.) 


mucous  membrane,  and  so  ample  room  is  afforded  for  dilatation  of 
the  vagina  during  the  passage  of  the  presenting  part  (v.  Fig.  154). 

As  the  presenting  part  descends,  it  offers  an  obstruction  to  the 
return  flow  of  blood  in  the  veins,  and  the  consequent  rise  in  intra- 
venous pressure,  aided  by  the  natural  hyperaemic  condition  of  the 
vaginal  mucous  membrane,  causes  a  serous  transudation  from  the 
vessels  into  the  peri-vaginal  and  perinaeal  tissues  and  on  the 
surface  of  the  vaginal  mucous  membrane.  The  effect  of  this 
transudation  is  to  render  the  tissues  more  distensile  and  so  capable 
of  dilatating  to  the  necessary  extent  without  laceration  occurring, 
and,  by  increasing  the  amount  of  vaginal  discharge,  to  reduce  the 
friction  between  the  vaginal  mucous  membrane  and  the  skin  of 
the  foetus  to  a  minimum. 

The  Effect  of  the  Uterine  Contractions  on  the  Perinaeum  and 
Neighbouring  Structures. — When  the  presenting  part  reaches  the 
pelvic  floor,  it  lies  on  the  levator  ani  muscle,  supported  in  turn 

18 


274  THE  PHYSIOLOGY  OF  LABOUR 

by  the  perinaeum.  As  each  contraction  occurs,  it  is  driven  down- 
wards a  little  and,  in  its  descent,  forces  downwards  and  forwards 
both  of  these  structures.  Then,  as  the  contraction  passes  off,  the 
presenting  part  again  recedes,  forced  upwards  by  the  resisting 
levator  ani  muscle.  This  procedure  recurs  several  times,  each 
time  the  presenting  part  coming  a  little  lower  than  the  time 
before,  but  each  time  slipping  back  again  into  its  former  position. 
Finally,  however,  a  contraction  comes  of  sufficient  strength  to 
drive  the  presenting  part  between  the  lateral  parts  of  the  muscle 
in  such  a  manner  that  the  latter  grips  the  part  above  its 
greatest  convexity,  and,  consequently,  is  enabled  to  hold  it  in 
this  position.  As  soon  as  this  occurs,  the  head  no  longer  recedes, 
but  remains  in  the  position  into  which  it  was  driven  by  the  con- 
traction. The  next  contraction  then  is  able  to  drive  it  out,  and 
during  this  process  the  maximum  distension  of  the  perinaeum 
occurs.  The  extent  to  which  the  perinaeum  is  distended  and  dis- 
placed forwards  and  downwards  can  be  easily  understood  from  its 
relative  measurements  before  and  during  the  expulsion  of  the 
presenting  part.  The  usual  antero-posterior  measurement  of  the 
normal  unruptured  perinaeum  prior  to  delivery  is  about  one 
and  a  half  inches,  while  at  the  time  of  maximum  distension  it 
measures  from  three  to  four  inches,  or  even  more.  At  the  same 
time,  there  is  a  downward  displacement  of  the  anus  and  a  curious 
alteration  in  its  shape.  The  anterior  margin  of  the  anal  orifice 
is  drawn  forwards  with  the  perinaeum  and  forms  almost  a  straight 
line,  while  the  convexity  of  the  posterior  edge  is  increased, 
probably  due  to  its  fixation  by  the  attachment  of  the  sphincter 
muscle  to  the  tip  of  the  coccyx.  At  the  same  time,  there  is  an 
eversion  of  the  rectal  mucous  membrane.  The  result  is  that  the 
anal  orifice  assumes  the  form  of  a  large  capital  D  (Hart*),  the 
straight  stroke  of  the  letter  towards  the  vagina,  its  antero- 
posterior diameter  almost  an  inch  in  length,  and  its  transverse 
diameter  slightly  more.  As  the  head  passes  through  the  vulva 
the  so-called  '  inevitable  laceration  of  labour '  occurs  in  the  case 
of  primiparae,  that  is,  the  tearing  of  the  posterior  commissure  of 
the  vagina. 

The  Effect  of  the  Uterine  Contractions  on  the  Pelvic  Joints  and 
Ligaments. — As  already  stated,  all  the  cellular  and  connective  tissue 
of  the  pelvis  becomes  softened,  oedematous,  and  hypertrophied 
during  pregnancy.  The  various  pelvic  ligaments  undergo  a 
similar  change,  especially  just  prior  to  parturition.  These  changes 
enable  an  increased  amount  of  movement  to  take  place  at  the 
various  joints,  and  the  mobility  of  the  sacrum  especially  is 
increased.  The  pressure  of  the  foetal  head  when  passing  the 
brim  is  thus  enabled  to  drive  the  base  of  the  sacrum  back- 
wards, increasing  thereby  the  conjugate  diameter  of  the  brim 
and  diminishing  that  of  the  outlet.  Later,  when  the  head  has 
descended  further,  the  lower  portion  of  the  bone,  no  longer 
*  '  Selected  Papers,'  p.  141. 


THE  EFFECT  OF  CONTRACTIONS  ON  THE  OVUM  275 

restrained  by  the  softened  sciatic  ligaments,  is  driven  upwards 
and  backwards,  and  the  outlet  is  widened,  while  at  the  same  time 
the  promontory  is  caused  to  project  more  prominently  forwards. 
It  is  probable  even  that,  owing  to  the  great  softening  of  the  liga- 
ments that  occurs  from  the  outflow  of  serous  fluid  into  them, 
the  sacrum  to  a  very  small  extent  may  be  driven  bodily  back- 
wards, and  by  its  wedge-shaped  form  may  cause  an  increased 
separation  of  the  ossa  innominata,  and  a  consequent  slight  aug- 
mentation of  the  transverse  diameter.  Even  greater  relaxation 
occurs  at  the  symphysis  pubis,  and  sometimes  at  the  end  of 
pregnancy  the  pubic  bones  may  be  made  to  move  upon  one 
another  at  this  articulation.  During  labour,  the  bones  become 
slightly  separated,  and  thus  increase  the  size  of  the  pelvic  inlet. 
Failure  to  return  to  the  normal  state  sometimes  gives  rise  to 
trouble  after  the  puerperium. 

The  Effect  of  the  Uterine  Contractions  on  the  Ovum. — As  has 
been  seen,  the  first  effect  of  the  uterine  contractions  on  the  ovum 
is  to  cause  the  latter  to  bulge  in  the  direction  of  least  resistance. 
As  at  the  same  time,  the  lower  uterine  segment  is  drawn  upwards 
over  the'  ovum,  a  slip,  i.e.,  a  motion  in  opposite  directions,  takes 
place  between  the  membranes  forming  the  lower  pole  of  the 
ovum  and  the  lower  uterine  segment.  This  results  in  a  detach- 
ment, to  a  greater  or  less  extent,  of  these  membranes  from  the 
underlying  decidua,  a  process  which  is  accompanied  by  slight 
bleeding.  This  blood,  mingled  with  the  mucous  fluid  which 
comes  from  the  cervical  glands,  produces  the  so-called  '  show ' 
which  usually  ushers  in  labour.  Another  result  of  this  detach- 
ment of  the  membranes  is  the  production  of  the  so-called  '  bag 
of  membranes,'  the  term  applied  to  that  part  of  the  mem- 
branes which  are  felt  protruding  through  the  uterine  orifice 
during  labour.  No  further  change  takes  place  in  the  ovum 
until  the  dilatation  of  the  cervix  is  complete.  Then,  in  conse- 
quence of  the  loss  of  support  which  the  undilated  portion  of  the. 
cervix  previously  furnished,  the  membranes  rupture,  and  the 
liquor  amnii,  which  constitutes  the  fore-waters,  escapes.  The 
manner  in  which  premature  rupture  of  the  membranes  is  pre- 
vented has  been  already  explained.  As  a  rule,  both  chorion 
and  amnion  rupture  simultaneously,  and  the  site  of  rupture  is 
anywhere  in  the  unprotected  area.  In  some  cases,  however, 
the  amnion  may  rupture  first,  either  over  the  area  of  detach- 
ment, or,  more  commonly,  higher  up  in  the  uterus,  and  in 
this  way  fluid  may  find  its  way  between  the  membranes,  con- 
stituting an  amnio  chorionic  pouch.  Such  a  pouch  may  also  be 
produced  by  transudation  of  liquor  amnii  through  the  amnion, 
which  has  been  shown  to  be  the  more  permeable  of  the  two  mem- 
branes (Pinard),  The  rupture  of  a  pouch  formed  in  the  latter 
manner,  either  before  or  during  labour,  has  frequently  been 
mistaken  for  the  rupture  of  the  membranes.  The  condition  is 
known  as  amniotic  hydrorrhcea. 

18—2 


276  THE  PHYSIOLOGY  OF  LABOUR 

In  rare  cases,  the  amnion  or,  more  rarely  still,  both  membranes, 
may  persist  unruptured  even  until  after  the  birth  of  the  head, 
when  they  usually  tear  across  round  the  neck  of  the  foetus. 
Sometimes,  they  may  instead  tear  away  from  the  placenta  and 
the  child  be  born  entirely  enveloped  in  the  membranes,  or  in  very 
rare  cases  the  entire  ovum  may  be  expelled  intact.  The  latter 
are,  however,  only  likely  to  occur  in  the  case  of  a  small  ovum, 
and  are  relatively  common  in  the  case  of  miscarriages.  As  is 
well  known,  the  term  'caul '  is  applied  to  the  investing  membrane 
by  the  public,  and  to  it  superstition  has  attached  various  pro- 
perties, the  most  notable  of  which  is  that  of  saving  the  owner  of 
such  a  possession  from  death  by  drowning.     An  infant  who  is 


Fig.  155, — Diagram  representing  Effect  of  General  Contents 
Pressure  prior  to  Rupture  of  Membranes. 

+  ,  Area  of  uterine  contractions  ;    -  ,  area  of  uterine  relaxation. 

born  in  a  '  caul '  is  also   credited  with   the  prospect  of  a  most 
fortunate  future. 

The  manner  in  which  the  force  of  the  uterine  contractions  is 
transmitted  to  the  foetus  varies  according  to  the  relation  of  the 
foetus  to  the  investing  uterus.  The  contractions  of  the  uterine 
muscle  result  in  an  increase  in  the  intra-uterine  pressure,  and  hence 
in  the  creation  of  a  force  which  is  termed  variously  the  '  general 
intra-uterine  pressure '  or  the  'general  contents  pressure.'  If  the  foetus 
is  floating  in  the  liquor  amnii,  the  membranes  being  unruptured 
and  the  presenting  part  still  unfixed,  this  force  acts  as  a  general  and 
uniform  pressure  over  all  parts  of  the  foetus,  and,  consequently, 
does  not  tend  to  alter  the  position  of  the  latter  (v.  Fig.  155).  If, 
however,  the  presenting  part  is  fixed  in  the  pelvis,  and  is  of  such 
a  nature  that  it  can  completely  fill  the  lower  uterine  segment,  then, 
as  has  been  described,  the  contraction  of  the  longitudinal  bands 


THE  EFFECT  OF  CONTRACTIONS  ON  THE  OVUM  277 

of  muscle  fibres  draw  the  lower  segment  upwards  until  there  is 
a  girdle  of  contact  all  round  between  it  and  the  presenting  head. 
As  soon  as  this  occurs,  the  hind-waters  are  shut  off  from  the  fore- 
waters  and  the  '  general  intra-uterine  pressure '  is  only  transmitted 
to  the  foetal  body  and  such  part  of  the  head  as  is  above  this  girdle 
of  contact.  The  result  is  that  a  force  equal  to  the  general  intra- 
uterine pressure  acts  on  the  part  of  the  head  which  is  above  the 
girdle  of  contact,  and  tends  to  drive  it  downwards  (v.  Fig.  156). 
This  force,  be  it  noted,  acts  uniformly  over  the  basal  area  of  the 
head,  and,  consequently,  does  not  tend  to  alter  the  relation  of  the 
latter  to  the  body,  but  solely  to  drive  the  head  directly  down- 
wards. When,  however,  the  liquor  amnii  has  in  part  escaped  and 
the  uterine  wall  is  in  contact  with  the  foetal  body,  direct  uterine 


Fig.  156. — Diagram  representing  Effect  of  General  Contents 
Pressure  after  Rupture  of  Membranes. 

pressure  on  the  body  results,  and  another  force,  which  from  its 
tendency  to  restore  the  uterus  to  its  original  form  is  known  as 
'form-restitution  force,'  comes  into  play.  The  circular  fibres  of 
the  uterus  contracting  strongly,  cause,  as  we  know,  a  diminution 
in  the  transverse  and  antero-posterior  diameters,  and  so  exert 
a  lateral  pressure  upon  the  foetus.  This  pressure  tends  to 
straighten  the  foetal  body  and  brings  about  an  actual  increase 
in  length  of  about  1^  inches.*  This  brings  the  fundal  pole  of 
the  foetus  into  contact  with  the  fundus  of  the  uterus,  with  the 
result  that  the  contractions  of  the  longitudinal  bundles  of  muscle 
fibre  cause  a  force  which  acts  directly  downwards  on  the  fundal 
pole.  The  resultant  of  these  two  forces — the  circular  force  which 
straightens  the  foetal  body,  and  the  downward  force  which  acts 
on  its  fundal  pole — is  a  force  termed  'foetal  axis  pressure,'  which 
acts  directly  down  the  body  of  the  foetus  and  is  transmitted  to  the 
head  through  the  spinal  column  (v.  Fig.  157).     This  force,  there- 

*  Schaeffer,  '  Obstetric  Diagnosis  and  Treatment,'  p.  68,  American  edition  . 


278 


THE  PHYSIOLOGY  OF  LABOUR 


fore,  does  not  act  uniformly  over  the  base  of  the  head,  and  con- 
sequently is  capable  of  producing  a  change  in  the  relation 
between  the  head  and  the  trunk. 

To  sum  up,  the  forces  which  act  on  the  fcetus  are  two  in 
number  : — 

(i)  The  general intra-uterine  pressure,  acting  uniformly,  at  first 
over  the  entire  foetus  and  subsequently  over  such  part  of  the  foetus 
as  is  above  the  girdle  of  contact  of  the  lower  uterine  segment.  It 
is  the  most  important  force,  and  is  present  during  the  whole  of 
labour  save  in  the  rare  cases  in  which  the  entire  liquor  amnii  has 
escaped. 

(2)  The  form-restitution  force,  due  to  the  tendency  of  the 
uterus  to  return  to  its  normal  shape,  acting  on  whatever  parts  of 
the  foetus  come  into  direct  contact  with  the  uterine  wall  after 


Fig.  157. — Diagram  representing  '  Fcetal-axis  Pressure.' 

rupture  of  the  membranes.  As  soon  as  this  occurs,  it  results 
in  the  production  of  a  single  force  acting  downwards  along  the 
axis  of  the  fcetus  —foetal  axis  pressure. 

As  soon  as  the  membranes  have  ruptured,  the  contractions  of 
the  uterus  drive  the  foetus  downwards  into  the  vagina,  and  finally 
expel  it  complete.  The  remainder  of  the  liquor  amnii  accom- 
panies and  follows  the  birth  of  the  foetus.  The  various  alterations 
in  the  position  and  the  attitude  of  the  fcetus  which  occur  during 
this  process  are  termed  the  mechanism  of  labour,  and  as  they 
differ  according  to  the  presentation  of  the  fcetus,  they  will  be 
discussed  inthe  chapters  on  the  various  presentations. 

In  addition  to  -these  alterations,  changes  take  place  in  the  shape 
of  the  foetal  head  as  a  result  of  the  pressure  it  undergoes  in  its 
passage  through  the  pelvis.  These  changes  are  known  as  the 
moulding  of  the  head,  and  result  in  a  diminution  of  those 
diameters  which  are  most  compressed  with  a  compensatory 
elongation    of   those   which  are  not    compressed.     As  has  been 


THE  CAPUT  SUCCEDANEUM 


179 


already  shown,  the  moulding  of  the  head  is  rendered  possible 
by  the  presence  of  the  sutures  and  fontanelles.  The  precise 
nature  of  the  changes  which  occur  differs  according  to  the  pre- 
sentation, and  will  be  referred  to  in  its  proper  place.  Speaking 
generally,  however,  it  may  be  said  that,  as  a  rule,  one  parietal 
bone  slides  under  another,  the  frontal  bone  slides  under  the 
parietal  bones,  and  the  occipital  bone  does  the  same.  The  carti- 
lage between  the  squamous  and  temporal  portions  of  the  petrous 
bone  acts  as  a  hinge,  and  so  allows  the  former  portion  to  be 
pressed  inwards. 

Another  change  which  takes  place  is  the  formation  of  the 
'  caput  succedaneum,'  the  term  applied  to  the  sero-sanguineous 
swelling  which  forms  on  the  unprotected  area  of  the  presenting 
part—  i.e.,  the  area  corresponding  to  the  uterine  orifice — in  con- 


Fig\  158. 


-Coronal  Section  through  Fcetal  Head  at  the  Site  of  the 
Caput  Succedaneum.     (After  Ribemont-Dessaignes.) 


sequence  of  the  pressure  to  which  the  remainder  of  the  body  is 
subjected.  The  caput  succedaneum  is  a  tolerably  firm  swelling 
of  doughy  consistency,  and  which  pits  upon  pressure.  It  is 
formed  by  a  transudation  of  lymph  from  the  vessels  into  the 
tissues  of  the  scalp,  with  a  little  added  blood  due  to  minute 
haemorrhages,  the  result  of  the  laceration  of  small  vessels 
(v.  Fig.  158).  Its  size  depends  upon  the  duration  of  labour  and 
the  strength  of  the  uterine  contractions.  The  site  of  the  caput 
of  necessity  varies  according  to  the  nature  of  the  presentation 
and  the  position  of  the  foetus,  and  its  exact  site  also  changes 
during  labour  according  as  the  presenting  part  flexes,  extends, 
and  rotates.  This  will  be  again  referred  to.  The  caput  succe- 
daneum usually  disappears  completely  in  from  twenty-four  to 
forty-eight  hours  after  birth.  In  cases  in  which  it  forms  on  the 
face,   marked   temporary    disfigurement    often    results   owing   to 


2So 


THE  PHYSIOLOGY  OF  LABOUR 


distortion  of  the  features,  and  may  cause  the  parents  considerable 
anxiety.     It  is,  however,  only  temporary. 

The  contractions  of  the  uterus  return  a  shcrt  time  after  the 
birth  of  the  foetus,  and  bring  about  the  detachment  of  the  placenta 
and  the  decidua  and  their  expulsion.  The  exact  nature  of  the 
mechanism  by  which  these  processes  are  effected  cannot  be 
regarded  as  completely  ascertained.  The  most  obvious  and  com- 
monly accepted  theory  is  that  of  Schultze.*  He  considered  that 
the  placenta  was  first  detached  in  consequence  of  a  '  slip'  of  the 
uterine  wall  on  it,  consequent  on  the  shrinkage  which  occurs  in 


RP 


Fig.   159. — The  Separation  of  the.  Placenta:  Schultze's  Mechanism. 
RP,  Retro-placental  clot;  P,  placenta;  RR,  retraction  ring;  M,  membranes. 


the  placental  site  as  the  uterus  contracts  down  after  the  birth  of 
the  foetus  ;  that  blood  escaped  from  the  uterine  vessels  into  the 
retro-placental  space  thus  formed,  completed  the  detachment,  and 
at  the  same  time  drove  the  placenta  downwards  into  the  mem- 
branes with  its  foetal  surface  lying  lowest  ;  and  that  the  contrac- 
tions of  the  uterus,  acting  on  this  hsematoma,  completed  the 
expulsion  of  the  placenta  from  the  upper  segment  of  the  uterus 
(v.    Figs.    159,    160).     Matthews  Duncan, f    on    the    other    hand 

*   '  Nachgeburtslosung,'  Deutsche  Med.  Wochen.,  1880,  Nos.  51,  52. 
•j-  Edinburgh  Obstet.  Trans.,  vol.  ii.,  331. 


THE  DETACHMENT  OF  THE  PLACENTA 


281 


considered  that  the  placenta,  after  its  detachment,  was  expelled 
from  the  uterus  with  its  lower  border  first,  and  that  it  passed 
through  the  retraction  ring  as  a  button  passes  through  a  button- 
hole (v.  Figs.  161,  162).  The  Edinburgh  School,  in  the  persons 
of  Hart  and  Barbour,  brings  forward  two  theories,  as  to  the 
cause  of  placental  separation  and  expulsion,  which  differ  from 
the  foregoing.  Barbour  *  considers  that  he  has  proved  that 
the  placental  site  can  be  reduced  to  a  space  of  ^  by  4  inches 
without  causing  detachment  of  the  placenta.     He  also  considers 

RP  RR  P 


Fjg.   160. — The  Expulsion  of  the  Placenta  from  the  Uterus: 

Schultze's  Mechanism. 

RP,  Retro-placental  clot;   P,  placenta;  RR,  retraction  ring;  M,  membranes. 


that  if  the  uterus  contracts  firmly  down  upon  the  placenta  it  will 
tend  to  expel  the  latter,  and  that  during  this  process  separation 
will  naturally  occur.  Accordingly,  he  attributes  the  separation 
of  the  placenta  to  the  diminution  of  the  placental  site  to  an  area 
of  less  than  4  by  \\  inches,  plus  the  action  of  the  uterus,  as  a 
whole,  on  the  placental  mass.  Hart,  on  the  othes-  hand,  while 
agreeing  that  the  main  cause  of  the  separation  of  the  placenta  is 
to  be  found  in  disproportion  between  its  area  and  the  area  of  the 

*  Edin.  Med.  Joiirn.,  p.  301,  October,  1895. 


282 


THE  PHYSIOLOGY  OF  LABOUR 


placental  site,  considers  that  the  cause  of  the  disproportion  is,  not 
the  placental  site  becoming  smaller  than  the  placental  area,  but  its 
becoming  larger  than  the  latter.  His  reasons  for  this  belief  are 
as  follows  : — So  long  as  the  placenta  has  either  or  both  its  blood- 
supplies  from  the  maternal  or  foetal  vessels  intact,  it  can  diminish 
or  increase  in  size  pari  passu  with  the  portion  of  uterine  wall  to 
which  it  is  attached.  When,  however,  the  supply  from  both 
foetus  and  mother  is  cut  off,  the  placenta  can  diminish  pari  passu 
with   the   uterine   wall,  but   cannot   again   expand    as   the   wall 


C    M 

Fig.   161. — The  Separation  of  the  Placenta:  Matthews  Duncan's 

Mechanism. 

P,  Placenta;  RR,  retraction  ring  ;  C,  blood-clot ;  M,  membranes. 


relaxes.  Consequently,  separation  occurs  during  the  relaxations 
of  the  uterus,  which  occur  after  the  foetal  circulation  has  ceased 
owing  to  the  ligation  of  the  cord  or  other  cause,  and  after  the 
maternal  supply  has  been  cut  off  by  the  retraction  of  the  uterus. 

To  us,  Schultze's  theory  appears  the  most  obvious  and  the  most 
natural,  save  in  cases  in  which  the  placenta  extends  almost  or 
quite  into  the  lower  uterine  segment.  In  such  cases,  a 
haematoma  does  not  in  all  probability  form,  or  if  it  does  the 
accumulated  blood  escapes  before  it  is  sufficient  in  amount 
to   influence  the  attachments   or  position   of  the   placenta,  and 


THE  EXPULSION  OF  THE  PLACENTA 


283 


the  placenta  is  probably  wholly  detached  by  a  slip  of  the  uterine 
wall  upon  it.  It  is  probable  that,  in  these  cases,  Matthews 
Duncan's  mechanism  of  expulsion  occurs. 

The   following   figures  (Pinard    and    Lepage*),  the    result  of 
7,682    normal    confinements,   show  the   very  much   greater   fre- 


RR  P 


Fig.  162. — The  Expulsion  of  the  Placenta  from  the  Uterus  : 
Matthews  Duncan's  Mechanism. 

P,  Placenta;  RR,  retraction  ring  ;  M,  membranes. 


quency  with  which  the  placenta  is  expelled  with  its  fcetal  surface 
presenting : — 


The  foetai  surface  presented  in 

The  edge  presented  in     - 

The  uterine  surface  presented  in 


6,206  cases,  or  80-79  per  cent. 

1,077  cases,  or  i3-4    per  cent. 

399  cases,  or    5  66  per  cent. 


When  the  placenta  has  been  expelled  from  the  upper  uterine 
segment  it  lies  in  the  lower  segment,  from  which  it  is,  as  a  rule, 
expelled  artificially.  If  its  expulsion  is  left  to  the  natural  efforts, 
it  takes  place  sometimes  within  a  comparatively  short  time  as  a 
result  of  strong  bearing-down  efforts  on  the  part  of  the  patient, 
united  with  the  contractions  of  the  vaginal  muscles.  More 
frequently,  however,  the  process  is  much  more  prolonged,  and 
is  only  completed  after  several  hours.     The  apparent  failure  of 

*  Ribemont-Dessaignes  and  Lepage,  '  Precis  d'Obstetrique,'  vol.  i.,  p.  504. 


284  THE  PHYSIOLOGY  OF  LABOUR 

nature  to  effect  the  expulsion  of  the  placenta  from  the  vagina  is 
mainly  the  result  of  the  artificial  surroundings  and  position  of  the 
patient.  In  savage  races,  even  at  the  present  time,  where  the 
mother  is  confined  move  feronim,  the  placenta  is  usually  expelled 
by  the  natural  efforts,  and  most  commonly  by  an  effort  in  the 
squatting  position,  as  in  defalcation.  In  civilized  races,  on  the 
other  hand,  the  acquired  necessity  for  remaining  in  the  recumbent 
position  prevents  the  exertion  of  a  sufficient  degree  of  force,  and 
consequently  artificial  aid  is  required. 

The  Effects  of  the  Uterine  Contractions  on  the  Maternal  System. 
— During  a  contraction  of  the  uterus,  the  heart-rate  of  the  mother 
is  progressively  increased  as  the  contraction  rises  to  its  acme, 
when  it  attains  a  rate  of  twelve  or  more  beats  per  minute' 
(Winckel)  in  excess  of  its  previous  rate.  This  again  gradually 
falls  as  the  contraction  passes  off,  until  the  former  rate  is  regained 
in  the  interval  between  the  contractions.  This  contrasts  with  the 
effect  of  the  contractions  upon  the  foetal  heart-rate.  In  the  latter, 
the  rate  gradually  falls,  until  it  reaches  a  minimum  at  the  acme  of 
the  contraction,  and  then  again  increases  as  the  contraction 
passes  off.  The  slowing  which  occurs  during  a  pain  may  be 
as  much  as  10  or  12  beats  in  ten  seconds,  or  at  the  rate  of  from 
60  to  72  per  minute  (Kehrer  and  Ziegenspeck*).  That  is  to 
say,  during  a  contraction  the  fcetal  heart-rate  falls  from  an 
average  rate  of  140  per  minute  to  an  average  of  from  80  to 
68.  This  slowing  is  somewhat  more  marked  towards  the  end  of 
the  first  stage  and  in  the  second  stage.  Ij;  is  usually  explained 
as  due  to  one  of  the  following  causes  : — 

(1)  Increased  pressure  on  the  surface  ol  the  foetus,  causing 
increased  peripheral  resistance  in  the  bloodvessels  and  slowing 
of  the  heart,  in  accordance  with  the  observation  made  by  Marey 
that  the  frequency  of  the  heart  is  in  inverse  proportion  to  the 
peripheral  resistance. 

(2)  Compression  of  the  fcetal  head,  causing  irritation  of  the 
vagus.  This  would  account  for  the  fact  that  the  diminution  in 
rate  at  the  acme  of  the  contraction  is  more  marked  in  the  second 
stage  than  in  the  first  stage. 

(3)  Interference  with  the  placental  circulation,  and  a  cor- 
responding degree  of  asphyxia. 

The  respiratory  rate  of  the  mother  is  somewhat  more  frequent 
during  labour  than  it  is  during  pregnancy  (20-7  per  minute  in 
labour  to  18*7  in  pregnancy — Winckel),  and  falls  during  a  con- 
traction to  an  extent  equal  to  a  difference  in  rate  of  about  6-8  per 
minute  (Winckel).  In  some  cases,  a  more  marked  increase 
occurs  during  labour.  The  maternal  temperature  is  said  to  rise 
during  a  contraction  from  0*36  to  0-93  of  a  degree  Fahrenheit. 

*  Kehrer,  '  Vergleich.  Phys.  der  Geburt.  des  Menschen  und  der  Saugethiere,' 
S.  41.  Ziegenspeck,  'Einfluss  der  Wehe  auf  die  Herzthatigkeit  des  Kindes,' 
I.  D.,  Jena,  1885. 


CHAPTER  II 


THE  STAGES  AND  PROGNOSIS  OF  LABOUR 


The  Duration  of  Labour — The  Stages  of  Labour ;  The  Premonitory  Stage, 
Phenomena;  Diagnosis;  The  First  Stage,  Duration,  Phenomena, 
Clinical  Events,  Diagnosis  ;  The  Second  Stage,  Duration,  Phenomena, 
Clinical  Events,  Diagnosis ;  The  Third  Stage,  Duration,  Phenomena, 
Clinical  Events,  Diagnosis — The  Symptoms  of  Prolonged  Labour — The 
Prognosis  of  Labour  ;  The  Statistics  of  the  Rotunda  Hospital  and  of 
the  Registrars-General  for  England  and  Ireland. 

In  this  chapter,  we  propose  to  discuss  the  phenomena  of  the 
stages  of  labour  from  a  more  clinical  standpoint  than  that  which 
was  adopted  in  the  previous  chapter.  A  few  repetitions  may- 
occur  in  its  course,  but  these  will  only  be  made  where  they  are 
calculated  to  assist  the  student. 

Duration. — The  duration  of  labour  varies  very  greatly  in 
different  women,  and  depends  to  a  considerable  extent  upon 
the  lie,  presentation,  and  size  of  the  foetus,  the  capacity  of  the 
genital  passages,  and  the  strength  of  the  uterine  contractions.  If 
the  fcetus  is  of  normal  size  and  presents  by  the  vertex,  if  the 
pelvis  and  genital  passages  are  of  their  normal  capacity,  and 
if  the  uterine  contractions  are  of  their  normal  strength,  the 
average  duration  of  labour  is  in  primiparae  from  twelve  to  fourteen 
hours,  in  multipara?  from  six  to  eight  hours.  The  following 
figures  show  more  accurately  the  relative  duration  of  labour  in 
primiparae  and  multipara;  under  normal  circumstances.*  The 
figures  relating  to  primiparae  are  based  on  the  results  of  3,403 
cases,  those  relating  to  multiparas  on  4,130  cases: — 


1 
Duration  of  Labour.             Primiparae  (3,403  Cases). 

Multiparas  (4,130  Cases). 

Less  than  6  hours       -         -                15  per  cent. 
From    6  to  12  hours  -         -               40 
,,      12  to  18       ,,     -         -               29 

18  to  24       ,,     -         -                 9         ,, 
More  than    24       ,,     -         -                  7 

42  per  cent. 

40 

11 

5 

2 

*  Pinard  and  Lepage  at  the  Clinique  Baudelocque,  1891,  1895. 
285 


286  THE  PHYSIOLOGY  OF  LABOUR 


THE  STAGES  OF  LABOUR 

The  process  of  labour  is  divided  into  three  stages  : — The  first 
stage,  or  stage  of  dilatation ;  the  second  stage,  or  stage  of 
expulsion  ;  and  the  third  stage,  or  the  placental  stage.  In 
addition  to  these  three  stages,  it  is  convenient  to  recognise  an 
additional  stage — the  premonitory  stage — inasmuch  as  labour  is 
ushered  in  by  a  definite  train  of  symptoms  and  physical  signs. 

The  Premonitory  Stage. 

The  premonitory  stage  is  most  irregular,  both  in  the  time  of  its 
onset  and  in  the  degree  to  which  its  symptoms  occur.  As  a  rule, 
the  latter  first  show  themselves  a  day  or  two  before  labour, 
properly  so  called,  commences.  In  primiparae  the  symptoms  are 
well  marked,  in  multiparas  they  may  be  slight  or  altogether 
absent. 

Phenomena. — The  principal  phenomena  of  the  premonitory  stage 
are  as  follows  :  — 

(i)  The  Occurrence  of  False  Pains. — The  commonest  pheno- 
menon of  commencing  labour  is  the  occurrence  of  irregular  pains 
which  have  no  definite  seat,  but  are  felt  generally  over  the 
abdomen.  These  pains,  which  may  be  considered  as  inter- 
mediaries between  the  painless  contractions  of  pregnancy  and 
true  labour  pains,  are  known  as  false  pains,  or  dolores  presagientes. 
They  occur  at  widely  separated  intervals,  and  are  distinguished 
from  true  labour  pains  by  their  irregularity,  and  by  the  fact 
that  they  are  not  referred  to  the  back. 

(2)  Partial  Dilatation  of  the  Cervical  Canal,  and  Increased 
Softening  of  the  Cervix.  —  The  changes  which  occur  in  the 
cervix  during  this  stage  differ  in  primiparae  and  multiparas.  In 
primiparae,  there  is,  as  a  rule,  no  dilatation  of  either  the  internal 
or  the  external  os  until  labour  has  actually  commenced,  and  the 
changes  characteristic  of  this  stage  are  limited  to  increased 
softening,  due  to  hyperaemia  of  the  cervical  tissues.  In  multi- 
paras, on  the  other  hand,  the  external  os  usually  commences  to 
dilate  some  days  before  the  onset  of  labour,  so  that  the  finger 
may  be  passed  a  short  way  into  the  cervical  canal.  In  both 
primiparae  and  multipara,  the  operculum  or  plug  of  mucus 
which  fills  the  cervical  canal  is  expelled. 

(3)  The  Onset  of  the  'Show.' — The  show  is  the  term  applied  to 
a  blood-stained  mucous  discharge  which  escapes  from  the  cervix 
during  the  premonitory  stage.  It  is  composed  mainly  of  cervical 
mucus,  with  the  addition  of  a  small  amount  of  blood — the  result 
of  commencing  detachment  of  the  membranes  in  the  neighbour- 
hood of  the  internal  os. 

(4)  Swelling  of  the  Vulva. — A  slight  degree  of  swelling  of  the 
vulva  very  constantly  occurs.  It  is  due  to  the  increased  obstruc- 
tion offered  to  the  return  of  blood  owing  to  the  pressure  exerted 


THE  PHENOMENA  OF  THE  FIRST  STAGE  287 

upon  the  veins  by  the  descending  head,  and  also  to  hyperaemia  of 
the  vessels. 

To  this  list  the  falling  of  the  fundus  of  the  uterus  to  a  lower 
level  in  the  abdomen  and  the  fixation  of  the  foetal  head  are  very 
frequently  added.  At  the  end  of  the  thirty-sixth  week,  the  fundus 
has  reached  the  level  of  the  ensiform  cartilage,  while  at  the 
commencement  of  labour  it  is  found  to  be  midway  between  the 
ensiform  cartilage  and  the  umbilicus.  As,  however,  this  change 
gradually  occurs  during  the  last  three  weeks  of  pregnancy,  it  can 
hardly  be  considered  as  one  of  the  premonitory  symptoms  of 
labour.  The  fixation  of  the  foetal  head  is  equally  foreign  to  this 
stage.  In  primiparae  the  head  is,  as  a  rule,  fixed  in  the  pelvis 
during  the  last  few  weeks  of  pregnancy,  while  in  multiparas  it 
is  free  above  the  brim  until  labour  has  actually  commenced. 
Consequently,  in  neither  case  can  it  be  regarded  as  a  premonitory 
symptom. 

Diagnosis. — It  is  by  no  means  easy  to  determine  whether  the 
patient  has  reached  the  premonitory  stage  of  labour  or  not,  and 
the  question  can  only  be  answered  by  carefully  looking  for  the 
various  symptoms  and  physical  signs  which  have  been  described. 
The  occurrence  of  irregular  pains  is,  however,  sometimes  decep- 
tive, as  they  may  be  due  to  flatulence  or  other  similar  causes. 


The  First  Stage. 

The  first  stage,  or  the  stage  of  dilatation,  commences  with  the 
onset  of  true  uterine  contractions  and  the  accompanying  dilatation 
of  the  internal  os,  and  ends  with  the  full  dilatation  of  the  os  and 
the  rupture  of  the  membranes.  It  is  the  longest  of  the  three 
stages  of  labour,  and  occupies  on  an  average  in  primiparae  from 
eleven  to  twelve  hours,  and  in  multiparas  from  five  to  seven 
hours. 

Phenomena.  —  The  principal  phenomena  of  this  stage  are  as 
follows  :  — 

(1)  The  Occurrence  of  Uterine  Contractions. — The  occurrence 
of  the  true  uterine  contractions  of  labour  is  one  of  the  principal 
phenomena  of  the  first  stage.  They  differ  from  the  contractions 
which  have  previously  occurred  in  that  they  are  pain-causing 
contractions  that  they  are  rhythmical,  and  that  the  pain  they 
cause  is  referred  principally  to  the  back. 

(2)  The  Taking-up  and  Dilatation  of  the  Cervix. — As  a  result  of 
the  occurrence  of  contractions,  the  taking-up  of  the  cervical  canal 
commences.  This  process  has  been  already  fully  described,  and 
need  not  be  again  referred  to.  As  soon  as  it  is  complete,  the 
uterine  orifice  dilates  to  the  size  necessary  for  the  passage  of  the 
foetus. 

(3)  The  Rupture  of  the  Membranes. — As  soon  as  the  uterine 
orifice  is  completely  dilated,  the  membranes  rupture  as  a  result 


288  THE  PHYSIOLOGY  OF  LABOUR 

of  the  loss  of  the  support  which  they  previously  received  from 
the  cervical  walls. 

(4)  The  Fixation  of  the  Head. — If  the  head  is  not  already  fixed 
in  the  pelvis — as  is  the  rule  in  primiparse,  it  fixes  shortly  after 
the  commencement  of  uterine  contractions. 

Clinical  Events. — At  the  commencement  of  labour,  the  patient 
may  pursue  her  ordinary  Occupations,  save  when  a  pain  occurs. 
The  latter  at  first  are  felt  at  intervals  of  half  an  hour  or  more,  but 
as  the  stage  advances  they  become  more  frequent,  until  towards 
the  end  they  occur  every  two  or  three  minutes.  The  pain 
experienced  by  the  patient  is  referred  to  the  region  of  the  sacrum. 
It  is  usually  of  a  dull  aching  character,  and  may  be  so  severe  as 
to  cause  her  to  cry  out.  The  pulse  and  temperature  are,  as 
a  rule,  unaffected,  save  for  a  slight  increase  in  frequency  in  the 
former  during  a  contraction.  Gastric  disturbances  associated 
with  vomiting  are  of  common  occurrence,  particularly  towards 
the  end  of  the  stage. 

Diagnosis. — It  is  an  easy  matter  to  determine  the  onset  of 
labour  in  the  case  of  a  patient  in  whom  contractions  are  occurring 
forcibly  and  regularly.  It  is,  however,  a  most  difficult  matter  to 
be  certain  whether  labour  has  commenced  or  not  when  we  see  a 
patient  a  little  before  or  a  little  after  the  commencement  of  the 
stage,  as  all  the  symptoms  of  the  premonitory  stage  are  present 
during  the  first  stage  save  the  false  pains,  which,  together  with 
the  painless  contractions  of  the  uterus,  disappear,  and  are  replaced 
by  painful  contractions.  The  latter  can  be  recognised  by  laying 
the  hand  flat  on  the  abdomen,  and  determining  the  fact  that  the 
occurrence  of  pain  is  preceded  and  accompanied  by  an  easily 
perceptible  hardening  of  the  uterus.  They  are  a  sure  sign  that 
labour  has  commenced.  Further,  if  the  foetal  head,  which  a 
previous  examination  showed  to  be  above  the  pelvic  brim,  is  now 
found  to  be  fixed,  we  know  labour  has  commenced.  The  most 
reliable  sign  furnished  by  vaginal  examination — indeed,  perhaps 
the  earliest  sign  of  the  onset  of  labour — consists  in  the  com- 
mencing dilatation  of  the  internal  os.  This  is  ascertained  by 
passing  the  finger  into  the  cervical  canal,  when  the  presenting 
part,  or  the  membranes,  will  be  felt  instead  of  the  ring  of  cervical 
tissue  which  formerly  barred  the  further  progress  of  the  finger, 
and  at  the  same  time  it  will  be  noted  that  an  actual  shortening  of 
the  cervix  has  taken  place.  If,  during  a  contraction,  there  is  a 
further  dilatation  of  the  internal  os,  as  shown  by  the  fact  that 
the  membranes  bulge  through  it  to  an  increasing  extent,  we  have 
a  definite  sign  that  labour  has  started. 

The  Second  Stage. 

The  second  stage,  or  stage  of  expulsion,  commences  with  the 
full  dilatation  of  the  os  and  the  rupture  of  the  membranes,  and 
ends  with  the  expulsion  of  the  child.     Its  average  duration  is 


THE  PHENOMENA  OF  THE  SECOND  STAGE 


289 


from  one  to  two  hours  in  primiparae,  and  from  ten  to  fifteen 
minutes  in  multiparas.  It  varies  considerably  in  individual  cases, 
as  is  shown  by  the  following  table,  which  has  been  compiled 
from  the  results  ascertained  in  the  case  of  3,428  primiparae  and 
4,099  multipara?."  In  every  case  the  maternal  passages  were 
normal,  and  the  child  was  delivered  alive. 


Duration  of  Second  Stage. 

Primiparae  (3,428  Cases). 

Multipara;  (4,099  Cases). 

Less  than  15  minutes 
From  15  to  30     ,, 
,,      30  to  60     ,, 
,,      60  to  120  ,, 
Above  120  minutes    - 

22  per  cent. 

21         ,, 

26 

21 

10 

69  per  cent. 
17 

9 

4 

1 

It  is  usually  considered  that  in  the  case  of  elderly  or  very 
young  primiparae  the  process  of  labour  is  considerably  longer 
than  in  the  case  of  primiparae  between  twenty  and  thirty.  That 
this  was  so  was  denied  so  long  ago  as  the  time  of  Madame 
Lachapelle,f  and  her  statements  have  been  recently  supported  by 
the  statistics  which  have  been  personally  collected  by  Dube,]: 
who  gives  the  following  averages  : — - 


Primiparae  below 
20  (378  cases)  - 

Total  duration  of  labour     - 

,,          ,,          second  stage  - 

13  hours    5  mins. 
1  hour    15      ,, 

Primiparae       be- 
tween   20    and 
30  (378  cases)  - 

Total  duration  of  labour     - 

„          ,,          second  stage  - 

-  13  hours  28  mins. 

-  0         ,,    59      ,, 

Primiparae     over 
30  (378  cases)  - 

Total  duration  of  labour     - 

,,          ,,          second  stage  - 

-     13  hours  19  mins. 
1  hour    10 

These  figures  differ  so  considerably  from  what  we  conceive  to 
be  the  general  opinion  held  on  this  question  that  they  are  worthy 
of  attention. 

Phenomena. — The  chief  phenomena  of  the  second  stage  are  the 
continuance  of  involuntary  contraction  and  retraction  of  the 
uterine  muscle,  with  the  addition  of  the  voluntary  contractions  of 
the  accessory  muscles  of  labour,  and. the  consequent  expulsion  of 
the  foetus. 

*  Pinard  and  Lepage. 

f  'Pratique  des  Accouchements,'  memoire  i.,  p.  59. 

X  Ribemont-Dessaignes  and  Lepage,  '  Precis  d'Obstetrique,'  p.  344. 

19 


290  THE  PHYSIOLOGY  OF  LABOUR 

Clinical  Events. — The  nature  of  the  uterine  contractions  re- 
mains unchanged,  save  that  they  become  more  violent  and  last 
for  a  longer  time.  The  interval  between  them  is  also  lessened. 
They  vary  in  length  from  thirty  to  sixty  seconds,  and  occur 
every  five  to  seven  minutes  up  to  the  actual  time  of  expulsion, 
when  they  follow  one  another  almost  without  a  break.  The 
voluntary  contractions  of  the  abdominal  muscles  impart  to  the 
second  stage  pains  their  expulsive  character.  As  each  contrac- 
tion commences,  the  patient  fixes  her  diaphragm  by  closing  the 
glottis  after  a  deep  inspiration,  and,  contracting  her  abdominal 
muscles  to  the  utmost,  brings  all  the  force  she  can  to  bear  upon 
the  uterus  and  its  contents.  The  reason  that  these  voluntary 
expulsive  efforts  do  not  occur  during  the  first  stage  is  obvious. 
At  that  time,  the  undilated  cervix  offers  a  bar  to  the  advance  of 
the  uterine  contents,  and  hence  the  effect  of  the  contraction  of 
the  abdominal  muscles  is  merely  to  drive  the  entire  uterus  down- 
wards into  the  pelvis  without  in  any  way  furthering  the  expulsion 
of  the  ovum.  In  the  second  stage,  the  cervical  obstruction  is 
removed,  and  the  compression  of  the  uterus  by  the  voluntary 
contractions  of  the  abdominal  muscles  materially  assists  in 
hastening  the  expulsion  of  the  foetus.  Expulsion  commences  as 
soon  as  the  membranes  rupture,  provided  that  event  corresponds 
with  the  period  of  full  dilatation  of  the  uterine  orifice.  The  pre- 
senting part  is  driven  downwards  through  the  vagina  until  it 
reaches  the  perinaeum,  where  there  is  usually  a  little  delay.  As 
each  fresh  contraction  occurs,  the  presenting  part  advances  a 
little,  and  can  be  seen  at  the  vulva  separating  the  labia;  and  as 
the  contraction  passes  off  it  again  recedes  into  the  vagina. 
Finally,  it  descends  so  far  that  it  becomes  gripped  by  the  levator 
ani  muscle,  in  consequence  it  does  not  recede,  and  then,  in  all 
probability,  the  next  contraction  will  cause  its  expulsion.  As 
the  presenting  part  is  passing  over  the  perinaeum,  the  pain  caused 
is  so  severe  that  the  patient  is  compelled  to  cry  out.  This  act  is 
of  considerable  practical  importance,  as  by  the  opening  of  the 
glottis  the  voluntary  bearing-down  efforts  are  checked,  the  expul- 
sion of  the  foetus  is  slowed,  and  so  a  longer  time  is  given  to  the 
perinaeum  to  dilate. 

The  symptoms  of  the  second  stage  are  more  marked  than  are 
those  of  the  first,  owing  to  the  increased  strength  of  the  uterine 
contractions,  and  to  the  fact  that  the  passage  of  the  foetus  through 
the  vagina  increases  the  patient's  suffering.  The  frequency  of 
the  pulse-rate  and  of  respiration  are  slightly  increased  during  a 
contraction,  but  are  otherwise  unaffected,  and  profuse  sweating 
may  occur.  As  the  presenting  part  presses  more  and  more  upon 
the  rectum  the  patient  experiences  a  strong  desire  to  go  to  stool, 
although  there  is  usually  nothing  in  the  bowel  to  evacuate. 

Diagnosis. — The  diagnosis  of  the  onset  of  the  second  stage  can 
be  made  by  noting  the  change  in  the  character  of  the  pains,  and 
by  ascertaining  from  the  patient  herself  or  her  attendants  whether 


THE  PHENOMENA  OF  THE  THIRD  STAGE 


291 


the  membranes  have  ruptured  or  not.  If  a  vaginal  examination 
is  made,  the  condition  of  the  cervical  canal  can  be  determined. 
The  rate  of  advance  of  the  presenting  part  through  the  pelvis  can 
be  best  ascertained  by  abdominal  palpation. 


The  Third  Stage. 

The  third  stage,  or  placental  stage,  commences  as  soon  as  the 
foetus  has  been  expelled,  and  ends  with  the  delivery  of  the 
placenta  and  membranes.  It  is  difficult  to  estimate  its  average 
duration,  as  the  latter  depends  entirely  upon  the  manner  in 
which  the  stage  is  conducted.  If  the  expulsion  is  left  to  the 
natural  efforts,  the  average  duration  is  said  to  be  from  one  to 
three  hours  ;  but  this  estimate  is  probably  too  little.*  If,  how- 
ever, the  usual  method  is  adopted  of  waiting  until  the  placenta 
has  been  detached  and  expelled  from  the  uterus  by  the  uterine 
contractions,  and  of  then  expressing  it  by  the  Dublin  method,  the 
average  duration  of  the  stage  is  from  ten  to  fifteen  minutes. 

Phenomena. — The  principal  phenomena  of  the  third  stage  are 
the  continuance  of  intermittent  contractions  and  of  permanent 
retraction  of  the  uterine  muscle,  the  detachment  of  the  placenta, 
and  the  expulsion  of  the  latter,  first,  from  the  contractile  upper 
segment  of  the  uterus  into  the  lower  segment  or  into  the  vagina, 
and  then  from  the  latter  segment  externally. 

Clinical  Events. — Clinically,  it  is  most  convenient  to  consider 
the  third  stage  as  composed  of  two  periods,  in  accordance  with 
the  periods  of  placental  expulsion  to  which  we  have  just  referred. 
In  the  first  period,  the  placenta  is  detached,  and  is  expelled  below 
the  retraction  ring  ;  in  the  second  period,  it  is  driven  outside  the 
genital  passages.  We  shall  see  the  importance  of  recognising 
these  periods  when  we  discuss  the  treatment  of  the  third  stage, 
as  during  the  first  period  the  expulsion  of  the  placenta  is  left  to 
the  natural  efforts,  while  during  the  second  period  its  expulsion 
is  hastened  by  active  assistance. 

Immediately  after  delivery  the  patient  experiences  a  marked 
sense   of   relief,  due  to  the  almost  complete   cessation   of  pain. 

*  The  following  table  shows  the  results  of  100  cases  of  labour  in  which  the 
delivery  of  the  placenta  was  left  to  nature  (Kabierske,  Centralblatt  fur  Gynakol., 
1SS1):—  '       , 


Number  of  Cases. 

Duration. 

1 

Number  of  Cases. 

Duration. 

24 

1 
30  mins. 

5 

5  hours 

20 

1  hour 

3 

6      ,, 

25 

2  hours 

2 

s      ,, 

11 

3      ,, 

1 

12      „ 

9 

4      ,. 

•    ■ 

19 — 2 


292 


THE  PHYSIOLOGY  OF  LABOUR 


Her  temperature  may  be  slightly  higher  than  during  labour, 
while  the  pulse-rate  is  usually  somewhat  less  than  it  was  at  the 
end  of  the  second  stage.  The  subsequent  condition  of  the  patient 
entirely  depends  on  the  amount  of  blood  which  is  lost.  In  some 
cases  there  may  be  a  slight  increase  in  the  pulse-rate  and  a  fall  in  the 
temperature  of  one  or  two  degrees,  owing  to  the  amount  of  blood 


Fig.  163. — Profile  of  the  Abdomen  during  the  Third  Stage. 
The  placenta  is  still  in  the  uterus.     (After  Varnier.) 

lost,  and  to  the  chilling  of  the  patient  which  may  occur  during 
the  delivery  of  the  after-birth  and  the  necessary  cleansing  of  the 
parts.  The  pain  caused  by  the  uterine  contractions  during  this 
stage  is  not,  as  a  rule,  very  severe. 

Diagnosis. — The  descent  of  the  placenta  below  the  contraction 
ring — i.e.,  the  commencement  of  the  second  period  of  the  third 


Fig.   164. — Profile  of  the  Abdomen  during  the  Third  Stage. 

The  placenta  has  left  the  uterus  and  is  lying  in  the  lower  uterine  segment. 
Note  the  forward  bulging  of  the  abdominal  wall  above  the  symphysis,  due 
to  the  situation  of  the  placenta,  and  the  increased  height  of  the  uterus  in 
the  abdomen.     (After  Varnier.) 

stage — can  be  recognised  by  certain  changes  which  take  place. 
These  are  as  follows  : — 

(1)  The  Funis  Lengthens. — As  the  placenta  leaves  the  uterus 
and  comes  to  lie  in  the  vagina  the  cord  simultaneously  descends, 
and  consequently  the  extravaginal  portion  increases  in  length. 
This  increase  in  length  will  be  readily  recognised  if,  when  tying 
the  cord,  the  ligature  which  is  placed  next  the  mother  is  tied  as 


THE  SYMPTOMS  OF  PROLONGED  LABOUR  293 

close  to  the  vulva  as  possible.  It  thus  forms  an  indicator  on  the 
cord,  and  enables  any  elongation  of  the  extravaginal  portion  to 
be  readily  detected.  In  order  to  guard  against  the  error  which 
might  result  from  the  expulsion  of  a  loop  which  had  been  pre- 
viously coiled  up  in  the  vagina,  it  is  well,  before  tying  the  ligature, 
to  draw  gently  on  the  cord,  in  order  that  any  such  loop  may  be 
straightened  out. 

(2)  The  Fundus  of  the  Uterus  Rises  upwards  to  the  Umbilicus. 
— After  the  expulsion  of  the  foetus  the  body  of  the  uterus  sinks 
downwards  into  the  thinned-out  lower  uterine  segment  and  the 
vagina  under  the  pressure  of  the  abdominal  contents  and  the 
controlling  hand  of  the  obstetrician.  As  the  placenta  is  expelled 
from  above  the  contraction  ring,  it  comes  to  lie  in  the  lower 
segment,  and  pushes  the  upper  segment  upwards  out  of  the 
pelvis.  As  a  result  the  fundus,  which  at  first  lay  only  slightly 
above  the  pubis,  rises  until  it  reaches  almost  the  level  of  the 
umbilicus. 

(3)  The  Mobility  of  the  Uterus  is  Increased. — This  change 
also  depends  upon  the  alteration  in  the  position  of  the  body  of 
the  uterus.  When  the  latter  lay  in  the  pelvic  cavity,  and  still 
enclosed  the  placenta,  it  was  more  or  less  supported  all  round  by 
the  brim  of  the  pelvis,"  and  consequently  could  not  be  readily 
moved  from  side  to  side.  As  it  rises  out  of  the  pelvis  this  support 
is  lost,  and  consequently  it  becomes  more  mobile. 

(4)  The  Abdominal  Wall  bulges  Forwards  above  the  Pubis. — 
This  change  is  not,  as  a  rule,  as  well  marked  as  are  the  others 
we  have  mentioned.  It  occurs  in  some  cases,  and  is  due  to  the 
fact  that  the  placenta  lying  in  the  lower  uterine  segment  pushes 
forward  the  structures  lying  in  front  of  it,  and  so  causes  a 
prominence  above  the  pubis  resembling  a  full  bladder,  for  which 
it  can  easily  be  mistaken. 

The  Symptoms  of  Unduly  Prolonged  Labour. — It  is  a  matter 
of  extreme  practical  importance  to  recognise  the  symptoms  which 
show  that  the  patient  has  been  in  labour  as  long  as,  or  longer  than, 
is  safe.  The  first  and  most  constant  symptom  is  acceleration  of 
the  pulse-rate.  This  gradually  rises  from  a  rate  of  70  to  80  beats 
per  minute  to  one  of  120  to  160.  Occasionally,  a  patient  may 
have  a  rapid  pulse  from  the  commencement  of  labour,  and  in 
such  cases  due  allowance  must  be  made  for  this.  Another  sym- 
tom  which  very  commonly  accompanies  a  rise  in  pulse-rate  is 
elevation  of  the  temperature.  This,  however,  is  by  no  means  an 
invariable  accompaniment,  and  in  all  probability  does  not  directly 
depend  upon  the  long  continuance  of  labour.  It  is  more  likely 
to  be  due  to  the  decomposition  of  lochia  and  blood  in  the  vagina, 
and  so  to  be  the  symptoms  of  a  slight  saprsemic  infection.  Indeed, 
it  is  probable  that,  but  for  such  an  infection,  the  temperature 
would  fall  in  cases  of  undue  prolongation  of  labour  in  conse- 
quence of  the  gradual  diminution  of  the  strength  of  the  patient. 


294  THE  PHYSIOLOGY  OF  LABOUR 

The  appearance  of  the  patient  is  also  altered.  Her  face  assumes 
a  haggard  aspect,  is  drawn  and  anxious,  and  expressive  of  the 
degree  of  suffering  which  she  has  gone  through.  Her  skin 
becomes  dry  and  hot,  or  at  a  later  stage  may  be  covered  by  a 
cold  perspiration.  The  lips  are  dry,  and  sordes  accumulate  about 
them,  while  the  tongue  is  also  dry  and  brown. 

The  remainder  of  the  symptoms  are  the  result  of  the  changes 
which  are  taking  place  in  the  uterus  as  a  result  of  the  long  continu- 
ance of  contractions.  The  character  of  the  contractions  is  altered. 
In  some  cases,  they  temporarily  cease,  and  return,  perhaps,  again 
in  a  short  time,  or  they  may  die  away  altogether,  when  a  con- 
dition of  missed  labour  results.  In  other  cases,  they  become  more 
violent  and  painful,  and  after  a  time  lose  their  intermittent  char- 
acter altogether  and  become  continuous  or  tonic.  In  such  cases 
the  abdomen  becomes  tense  and  tender,  and  it  is  difficult  or  im- 
possible to  feel  the  foetal  parts.  The  muscle  fibre  of  the  round 
ligaments  shares  in  this  tonic  contraction,  and  the  ligaments  stand 
out  on  the  surface  of  the  uterus  as  tense  cords,  one  or  both  of 
which  can  be  readily  palpated.  The  most  important  change  in 
the  uterus  is,  however,  that  brought  about  by  the  retraction  of 
the  muscle  fibres.  In  consequence  of  this,  as  has  been  already 
explained,  the  walls  of  the  upper  segment  of  the  uterus  grow 
thicker  and  the  cavity  becomes  smaller  the  longer  labour  lasts, 
while  the  walls  of  the  lower  segment  become  thinner  and  its 
cavity  larger.  The  junction  between  the  two  segments — i.e.,  the 
retraction  ring — in  consequence  occupies  a  progressively  higher 
level  in  the  abdomen.  Another  result  of  retraction  shows  itself 
in  the  shortening  of  the  longitudinal  bands  which  run  down  into 
the  cervix,  and  which,  by  drawing  up  the  cervix,  cause  ballooning 
of  the  vault  of  the  vagina.  This  change  can,  of  course,  only  be 
noticed  in  cases  in  which  the  presenting  part  is  still  above  the 
brim. 

In  addition  to  recognising  the  symptoms  which  show  that  the 
mother  has  been  too  long  in  labour,  it  is  also  a  matter  of  im- 
portance to  recognise  the  symptoms  which  show  that  the  foetus 
is  suffering  from  the  undue  prolongation  of  labour.  As  in  the 
case  of  the  mother,  the  earliest  and  most  important  sign  of  such 
a  state  of  affairs  is  furnished  by  the  rate  of  the  heart.  If  the 
foetal  heart-rate  commences  to  rise  progressively  in  the  intervals 
between  the  contractions  of  the  uterus,  or,  on  the  other  hand,  to 
gradually  fall,  we  have  a  certain  sign  that  labour  has  lasted  too 
long.  Alterations  in  rate  between  120  and  160  are  of  common 
occurrence,  and  are  not  important ;  but,  once  either  of  these 
limits  is  past,  it  shows  that  the  foetus  is  in  distress.  Another  sign 
is  furnished  by  the  coming  away  of  meconmm,  unmixed  with 
liquor  amnii,  in  a  head  presentation.  The  foetus,  when  in  distress, 
as  a  rule  passes  meconium.  If  this  comes  away  well  mixed  with 
the  liquor  amnii  at  the  time  of  the  rupture  of  the  membranes, 
it  shows  that  the  foetus  was  in  distress  some  time  previously,  and 


THE  PROGNOSIS  OF  LABOUR  295 

if  the  fcetal  heart  is  at  the  time  beating  at  a  normal  rate,  that 
the  cause  of  the  distress  has  been  removed.  If,  however,  the 
meconium  comes  away  during  the  second  stage  unmixed  with 
liquor  amnii,  and,  apparently,  quite  recently  passed,  it  shows  that 
the  foetus  is  in  immediate  distress.  An  exception  to  this  must  be 
made  in  the  case  of  a  pelvic  presentation,  when  the  coming  away 
of  meconium  is  of  no  importance,  as  it  is  the  invariable  result 
of  pressure  over  the  abdomen  of  the  foetus,  associated  with  an 
absence  of  pressure  over  the  anus.  A  third  sign  is  furnished  by 
tumultuous  movements  of  the  foetus — a  fact  of  which  the  patient 
will  inform  us,  and  which  we  can  verify  ourselves  by  placing 
the  hand  on  the  abdomen. 


THE  PROGNOSIS  OF  LABOUR 

It  cannot  be  too  strongly  insisted  upon  that,  in  normal  labour, 
the  rate  of  mortality  for  both  mother  and  child  should  be  nil. 
Labour  is  a  physiological  process,  and,  as  such,  has  no  more 
an  inherent  rate  of  mortality  than  has  any  other  physiological 
process.  To  what,  then,  is  the  definite  mortality  rate  which 
undoubtedly  exists  in  childbed  due  ?  In  other  words,  why  does 
the  mother  or  foetus  ever  die  during  childbirth  ?  The  causes  of 
maternal  death  may  be  grouped  under  three  heads : — Purely 
obstetrical  causes ;  pre-existing  disease  of  the  mother ;  and 
accidental  causes. 

Group  I.  Purely  Obstetrical  Causes  of  Death. — Labour  can  only 
be  regarded  as  a  physiological  process  so  long  as  it  occurs  in  a 
physiological  manner.  Once  any  deviation  occurs  from  such  a 
manner,  then  it  becomes  a  pathological  process,  at  least  so  far  as 
that  deviation  is  concerned.  It  is  hard  to  define  what  exactly 
constitutes  a  physiological  labour ;  but,  at  any  rate,  it  is  safe  tq 
say  that  any  factor  which  interferes  with  the  mechanical  process 
of  labour,  or  which  tends  to  alter  the  course  which  labour 
normally  follows,  produces  a  pathological  labour  to  a  greater  or 
less  degree,  and  so  tends  to  a  similar  degree  to  cause  mortality. 
Thus,  mal-presentations  of  the  foetus,  rigidities  or  obstructions  in 
the  genital  passages,  detachments  of  the  placenta  prior  to  the 
expulsion  of  the  foetus,  abnormalities  in  the  foetus  or  in  the  other 
constituents  of  the  ovum,  and  such  other  causes  as  directly  tend 
to  make  labour  more  difficult,  may  all  be  considered  to  be  purely 
obstetrical  causes  of  maternal  and  foetal  mortality. 

Group  II.  Pre-existing  Disease  of  the  Mother. — In  all  cases  in 
which  the  mother  suffers  from  any  disease  of  sufficient  intensity  to 
be  influenced  by  constitutional  changes,  labour  will  be  attended 
by  a  rate  of  mortality.  There  is  nothing  strange  in  this.  The 
act  of  emptying  the  rectum  or  bladder  is  a  physiological  process, 
and  is  unattended  by  mortality  under  normal  circumstances,  but 
if  an  individual  suffers  from  cardiac  disease,  aneurysm,  or  such- 


296  THE  PHYSIOLOGY  OF  LABOUR 

like  pathological  condition,  the  mere  natural  straining  necessary 
to  perform  the  act  of  defalcation  or  micturition  may  be  the  causa 
causans  which  completes  the  breakdown  of  the  heart  or  the  rupture 
of  the  aneurysm.  It  is  not,  then,  to  be  wondered  at  that  a  process 
involving  so  severe  a  strain  on  the  system  as  does  parturition 
should  be  attended  with  a  high  rate  of  mortality  in  all  cases  in 
which  it  is  associated  with  serious  organic  disease  of  the  mother. 
Group  III.  Accidental  Causes. — Under  the  heading  accidental 
causes,  we  include  all  causes  of  mortality  to  which  the  process  of 
parturition  renders  the  mother  liable,  but  whose  occurrence  might 
have  been  avoided.  The  principal  example  of  such  causes  is 
septic  infection.  The  process  of  labour  renders  a  parturient 
woman  especially  liable  to  septic  infection;  but,  if  due  precautions 
are  taken,  septic  infection  in  the  case  of  previously  healthy  women 
should  not  occur,  and  hence  there  should  be  no  mortality  from 
it.     It  is  a  distinctly  preventable  accident  of  parturition. 

In  consequence  of  the  existence  of  these  various  causes  of 
mortality  during  labour,  it  is  impossible  to  expect  that  a  long 
series  of  labours  will  be  unattended  by  mortality,  but,  it  should 
be  clearly  fixed  upon  the  mind  of  the  obstetrician  that,  in  the 
absence  of  any  of  these  causes — that  is,  in  the  vast  proportion  of 
all  cases — there  should  be  no  mortality.  It  is  possible  to  go 
even  further  than  this.  At  the  present  day,  the  science  or  art  of 
midwifery — -whichever  it  may  be  termed — has  reached  so  high 
a  pitch  of  excellence  that  the  obstetrician,  who  has  attained  a 
proper  knowledge  of  his  subject,  should  be  able  to  look  forward 
with  confidence  to  the  successful  termination  of  almost  every 
case  of  purely  obstetrical  complication.  Moreover,  modern  know- 
ledge of  the  causes  and  prevention  of  sepsis  enable  him,  if  he  is 
careful,  to  almost  eliminate  all  mortality  from  septic  infection. 
Consequently,  the  mortality  of  labour  should  be  entirely 
attributable  to  those  cases  in  which  we  are,  at  present,  power- 
less to  avert  the  effects  of  labour  on  an  already  broken-down 
maternal  organism. 

It  will  be  readily  understood  that  there  is  a  difficulty  in  esti- 
mating what  may  be  considered  to  be  a  not  undue  rate  of 
mortality  in  all  labour  cases  taken  together.  It  is  easy  to  give 
the  rate  of  mortality  in  a  particular  hospital,  or  in  the  practice  of  a 
particular  obstetrician,  but  it  is  difficult  to  estimate,  even  approxi- 
mately, what  would  have  been  the  mortality  of  the  same  patients 
if  they  had  been  confined  under  more  or  less  favourable  circum- 
stances. One  thing  is,  we  fear,  rendered  very  obvious  by  statistics, 
namely,  that  the  rate  of  mortality  of  childbirth  has  not  yet 
reached  the  irreducible  minimum,  but  that  numerous  lives  are 
yearly  sacrificed  which  might  have  been  saved.  It  may  be  of 
some  assistance  to  those  who  wish  to  investigate  this  important 
subject  further  if  we  lay  before  them  three  sets  of  statistics  : — 

(i)  The  mortality  which  occurred  during  the  last  ten  years 
(1894-1903)  in  the  wards  of  the  Rotunda  Hospital. 


THE  PROGNOSIS  OF  LA  I  SOUR 


297 


(2)  The  mortality  which  occurred  during  the  last  seven  years 
(1897-1903)  in  the  Extern  Department  of  the  Rotunda  Hospital. 

(3)  The  mortality  which  occurred  during  the  last  ten  years 
(1894-1903)  in  England  and  Ireland,  as  gathered  from  the  respec- 
tive returns  of  the  Registrars-General. 

In  the  case  of  the  Rotunda  statistics,  we  have  classified  the 
deaths  according  to  the  three  groups  of  causes  to  which  we 
have  already  referred ;  but  in  dealing  with  the  returns  of  the 
Registrars-General  it  was  impossible  to  follow  the  same  pro- 
cedure. 'For  the  purposes  of  comparison,  however,  the  figures  in 
Groups  I.  and  II.  in  the  Rotunda  statistics  may  be  taken  as  com- 
parable with  the  figures  in  the  group  of  deaths  from  non-septic 
causes  in  the  returns  of  the  Registrars  -  General.  Also  as 
Group  III.  in  the  Rotunda  statistics  is  almost  entirely  composed 
of  deaths  from  septic  causes,  it  is  comparable  with  the  group  of 
deaths  from  septic  causes  in  the  official  returns.  In  certain  cases, 
the  allocation  of  cases  has  to  be  somewhat  arbitrary.  For  in- 
stance, there  is  a  difficulty  in  deciding  whether  a  death  from 
eclampsia  should  be  placed  in  Group  I.  or  Group  II.,  as,  although 
it  is  essentially  an  obstetrical  complication,  it  is  almost  invariably 
associated  with  pre-existing  disease.  The  same  remark  applies 
to  hyperemesis,  and  accidental  haemorrhage.  We  have  allocated 
deaths  from  eclampsia  and  hyperemesis  to  Group  II.,  and  deaths 
from  accidental  haemorrhage  and  pulmonary  embolus  to  Group  I. 
The  following  table  contrasts  the  statistics  of  the  Intern  and 
Extern  Departments  of  the  Rotunda  Hospital  : — 


Intern  Department. 

Extern  Department. 

Total 

Number  of 

Labours. 

Deaths. 

Total 

Number  of 

Labours. 

Deaths. 

15.205 

Groups. 

Total. 

14,818 

Groups. 

Total. 

I. 

II. 

III. 

I. 

II. 

in. 

15 

27 

Oil 

14 

56 

23 

8 

7 

38 

Percentage 
of  deaths. 

0-098 

0-092 

036 

Percentage 
of  deaths. 

015 

0-05 

004 

0-25 

These  figures  are  very  much  what  one  would  expect.  We 
see  that,  as  is  natural,  the  death-rate  from  purely  obstetrical 
causes  is  less  in  the  Intern  than  in  the  Extern  Department.  It 
is  impossible  that  the  woman  who  sends  for  medical  advice  and 


298 


THE  PHYSIOLOGY  OF  LABOUR 


assistance  at  the  last  moment,  and  on  whom  any  necessary- 
operations  have  to  be  performed  under  the  most  unfavourable 
circumstances,  can  be  as  favourably  situated  as  the  woman  who 
enters  the  wards  of  the  hospital.  We  next  see  that  the  death- 
rate  from  pre-existing  disease  is  considerably  higher  in  the  Intern 
than  in  the  Extern  Department.  This  is  also  natural,  as  patients 
who  are  seriously  ill  prior  to  delivery  frequently  desire  to  be 
confined  in  the  hospital,  and,  consequently,  the  number  of  labours 
terminating  what  may  be  called  pathological  pregnancies  is 
very  much  greater  than  in  the  Extern  Department.  The  relation 
between  the  deaths  in  Group  III.  is  not  so  easy  to  explain. 
It  may  be  assumed  that  these  figures  are  entirely  made  up  by 
deaths  from  sepsis  in  some  form,  and  why  the  death-rate  should 
be  higher  in  the  Intern  than  in  the  Extern  Department  is  not 
quite  obvious.  It  is  most  probable  that  the  figures  do  not 
represent  the  true  proportion.  The  figures  of  the  Intern  Depart- 
ment are  carefully  kept  and  are  correct,  but  it  is  obviously 
impossible  to  keep  the  figures  relating  to  the  Extern  Department 
with  the  same  completeness.  Consequently,  it  is  probable  that 
the  percentage  of  deaths  in  the  Extern  Department  from  septic 
infection  is  higher  than  the  figures  show. 

In  the  next  table,  the  combined  statistics  of  the  Intern  and 
Extern  Departments  of  the  Rotunda  Hospital  are  contrasted  with 
the  general  statistics  of  the  country  at  large  : — 


Rotunda  Hospital:  Combined 
Intern  and  Extern  Departments. 

England  and  Ireland:  Returns 
of  Registrars-General. 

Total 

Number  of 

Labours. 

Deaths. 

Total 

Number  of 

Labours. 

Deaths. 

30,023 

Groups. 

Total. 

Groups. 

Total. 

I.  and  II. 

III. 

Non- 
septic 
Causes. 

Septic 
Causes. 

73 

21 

94 

10,290,289 

28,646 

22,231 

50,877 

Percentage 
of  deaths. 

0'204 

0'066 

0*27 

Percentage 
of  deaths. 

0-278 

0216 

0494 

A  comparison  of  the  combined  statistics  of  the  Intern  and 
Extern  Departments  of  the  Rotunda  Hospital  with  those  of  the 
country  at  large  is  most  instructive.  In  the  first  place,  it  shows 
that  the  deaths  from  strictly  obstetrical  causes  and  from  pre- 


THE  PROGNOSIS  OF  LABOUR 


299 


existing  disease  are  even  less  in  hospital  practice  than  amongst 
outside  cases,  although  it  is  fair  to  assume  that  the  number  of  ab- 
normal and  complicated  labours  is  considerably  greater  in  hospital 
practice.  In  the  second  place,  it  shows  that,  whereas  the  death- 
rate  from  septic  infection  in  hospital  practice  was  6  per  10,000 
labours,  the  rate  throughout  the  country  was  21  per  10,000 
labours,  or  more  than  three  times  as  many.  This,  too,  in  spite 
of  the  fact  that  almost  half  the  cases  included  in  the  Rotunda 
statistics  were  confined  in  the  hovels  of  the  poor  under  the  most 
unfavourable  circumstances  ;  and  that  amongst  the  other  half — 
i.e.,  those  confined  in  the  hospital — it  is  but  natural  to  expect  a 
greater  number  of  cases  who  were  unduly  prone  to  septic  infection. 
It  is  no  easier  to  obtain  a  definite  idea  of  what  may  be 
considered  to  be  an  average  rate  of  mortality  amongst  infants 
than  it  is  amongst  mothers.  The  following  table  of  statistics  of 
the  Clinique  Baudelocque  shows  the  mortality  amongst  infants 
delivered  spontaneously  or  by  the  aid  of  the  forceps  daring  five 
years,  infants  dead-born  in  consequence  of  eclampsia  alone 
excluded  : — 


Total  Number  of 
Confinements. 

Infants  died  during 
Labour. 

Infants  died  after 
Birth. 

Primiparae     -         -         3,686 
Multipara?      -         -         4,321 
Total       -         -         8,007 ' 

14 
16 

30 

113 

108 
221 

According  to  this  table,  the  total  infant  mortality  during  birth 
under  the  conditions  stated  above  was  0*37  per  cent.,  or  1  in 
266-9,  and  the  infant  mortality  after  birth  2*76  per  cent.,  or  1  in 
36*23.  If  from  the  total  number  of  deaths  after  birth,  138  children 
are  excluded  who  died  as  a  result  of  prematurity  or  of  congenital 
malformations,  it  will  be  seen  that  the  percentage  of  those  who 
died  after  birth  was  1-05,  or  1  in  96-47.  If,  however,  all  cases  of 
labour — save  abortions — are  included,  we  shall  get  very  different 
results,  as  is  shown  by  the  following  table,  compiled  from  the 
statistics  of  the  Rotunda  Hospital  for  the  past  seven  years  : — 


Average. 

10,803 
64 

Immature  births,  recent  -.---'- 

1  in  168-8 

Premature  births,  recent 

109 

1  in    99- 1 

Full-term  births,  recent  -              -              -             .- 

212 

1  m    5095 

Macerated             .--_-. 

207 

1  in    52-18 

Putrid       ------ 

13 

1  in  815-61 

Total  number  born  dead              -             - 

605 

1  in    17-85 

Infants  born  alive  who  died  in  hospital-             -  , 

248 

1  in    43-56 

Total  number  born  dead  or  died  in  hospital 

853 

1  in    12-54 

CHAPTER  III 
CEPHALIC  PRESENTATIONS 

Vertex  Presentation  —  Frequency  —  ^Etiology  —  Positions  —  Diagnosis  — 
Mechanism  ;  First  Position  ;  Second  Position  —  Abnormalities  of 
Mechanism  ;  Hyper-rotation  of  Head  ;  Reversed  Rotation  of  Shoulders  ; 
Reversed  Rotation  of  Head  ;  Lateral  Obliquity  of  Head,  Posterior 
Asynclitism,  Anterior  Asynclitism — Moulding. 

The  term  '  cephalic  presentation '  includes  all  presentations  in 
which  the  head  lies  lowest.  The  frequency  and  the  causes  of 
cephalic  presentation  have  been  already  mentioned.  It  occurs  in 
96-66  per  cent,  of  all  cases,*  or,  if  only  full-time  cases  are  taken 
into  account,  in  97-36  per  cent.f  The  different  cephalic  pre- 
sentations must  be  discussed  separately. 


VERTEX  PRESENTATION 

The  term  '  vertex  presentation  '  is  applied  to  that  presentation 
in  which  the  head  presents  and  the  vertex,  or  space  between  the 
anterior  and  posterior  fontanelles  bounded  laterally  by  the  parietal 
eminences,  lies  lowest. 

Frequency. — The  relative  proportion  of  cases  in  which  a  vertex  ■ 
presentation  occurs  depends  greatly  upon  the  period  of  pregnancy 
at  which  delivery  takes  place  and  upon  the  condition  of  the  foetus. 
At  the  seventh  month,  vertex  presentations  are  said  to  occur  in 
83  per  cent,  of  cases  in  which  the  foetus  is  alive,  and  in  53  per 
cent,  of  cases  in  which  the  foetus  is  dead  (Churchill).  Before  the 
seventh  month  the  percentage  of  vertex  presentations  is  less, 
while  at  full  term  vertex  presentation  occurs  in  97  per  cent, 
of  living  children,  and  in  80  per  cent,  of  macerated  foetuses 
(Collins).  If  all  cases  of  labour  occurring  after  the  fourth  month 
are  grouped  together,  vertex  presentation  occurred  in  96-22  per 
cent.  (Rotunda  Hospital). 

/Etiology. — It  is  not  necessary  to  again  enter  at  any  length  into 

the  causes  of  vertex  presentation,  inasmuch  as  they  have  been 

already  fully  discussed.     Cephalic  presentations  are  the  result  of 

the  relation  between  the  shape  of  the  foetus  and  the  shape  of  the 

*  Rotunda  Hospital.  +  Pinard  and  Lepage. 

300 


THE  CAUSE  OF  VERTEX  PRESENTATION 


Fig.   165. — First  Vertex  Presentation,  with  the  Back  in  Front. 
The  head  presenting  at  the  brim,  as  felt  by  vaginal  examination. 


Fig.  166. — First  Position  of  the  Vertex,  the  Back  in  Front. 
(Farabceuf.) 


302 


THE  PHYSIOLOGY  OF  LABOUR 


Fig.  167. — First  Position  of  the  Vertex,  the  Back 
Behind.     (Faraboeuf.) 


Fig.  168.— First  Vertex  Presentation,  with  the  Back  Behind. 
The  head  presenting  at  the  brim,  as  felt  by  vaginal  examination. 


THE  POSITIONS  OF  THE  FCETUS 


303 


ovum,  of  the  action  of  gravity  upon  the  fcetus,  and  of  the  move- 
ments of  the  latter.  Once  a  cephalic  presentation  occurs,  the 
vertex  naturally  presents  in  consequence  of  the  normal  attitude 
of  the  fcetus. 

Positions. — The  fcetus  may  lie  in  one  of  two  positions,  as  has 
been  already  mentioned,  according  as  the  back  is  turned  towards 


Fig.   169. — Second  Position  of  the  Vertex,  the  Back  in  Front. 
(Faraboeuf.) 


the  left  or  the  right  side,  and  in  each  of  these  positions  the  back 
may  be  directed  anteriorly  or  posteriorly.  In  this  way  are  got 
the  four  positions  of  Naegele.  The  different  positions  may  then 
be  classified  as  follows  :  — 

In  front,  first  position  of  Naegele, 
sometimes    termed    the    left    oc- 
cipito-anterior,  or,  shortly,  L.O.A. 
First  position,  back  to  the  left,  and  -, 

Behind,  fourth  position  of  Naegele, 
the     left     occipito  -  posterior,    or 
I     L.O.P. 


304 


THE  PHYSIOLOGY  OF  LABOUR 


fin  front,  second  position  of  Naegele, 
the    right    occipito  -  anterior,    or 
R.O.A. 
Second  position,  back  to  the  right,  and  i 

Behind,  third  position  of  Naegele, 
the    right    occipito-posterior,    or 
I     R.O.P. 

The  difference  in  the  relative  frequency  of  these  positions  is 
very  marked.  The  first  position,  with  the  back  in  front  (first 
position  of  Naegele),  is  much  the  most  common,  and  next  in 
frequency  comes  the  second  position,  with  the  back  posteriorly 


Fig.  170. — Second  Vertex   Presentation,   with    the   Back   in   Front. 
The  head  presenting  at  the  brim,  as  felt  by  vaginal  examination. 

(third  position  of  Naegele).  According  to  Naegele,  one  or  other 
of  these  two  positions  occurs  in  99  per  cent,  of  vertex  presenta- 
tions, and  the  statistics  of  more  recent  French  writers  appear  to 
support  this  statement. 

The  statistics  of  Pinard   and  others*   taken  together  are  as 
follows  : — 


Position. 

Back  in  Front. 

Back  Behind. 

Total. 

First 
Second 

62-83 
0-99 

5^4 
30-54 

68-47 
30-53 

The  causes  of  the  frequency  with  which  the  transverse  diameter 
*  Ribemont-Dessaignes  and  Lepage,  '  Precis  d'Obstetnque,'  p.  347. 


THE  POSITIONS  OF  THE  FOZTUS 


305 


Fig.  171. — Second  Position  of  the  Vertex,  the  Back  Behind. 
(Faraboeuf.) 


Fig.   172. — Second    Vertex    Presentation,    with    the   Back    Behind. 
The  head  presenting  at  the  brim,  as  felt  by  vaginal  examination. 

20 


306 


THE  PHYSIOLOGY  OF  LABOUR 


of  the  foetus  corresponds  with  the  left  oblique  diameter  of  the 
pelvis  are  probably  as  follows  : — 

(i)  The  tendency  of  a  shoulder  to  lie  in  the  right  anterior 
quadrant  of  the  pelvis  in  consequence  of  the  action  of  gravity. 

(2)  The  tendency  of  the  antero-posterior  diameter  of  the  foetus 
to  correspond  to  the  right  oblique  diameter  of  the  pelvis  as  a 
result  of  the  usual  dextro-torsion  of  the  uterus. 

(3)  The  tendency  for  the  antero-posterior  diameter  of  the 
foetal  head  to  lie  in  the  right  oblique  diameter  of  the  pelvis  in 


A  B 

Fig.   173. — Diagram  representing  the  Fcetus  as  felt  by  Abdominal 
Palpation  in  Vertex  Presentation. 

The  unshaded  portions  of  the  foetus  are  those  which  are  felt  most  distinctly. 
A,  First  vertex,  back  in  front ;  B,  second  vertex,  back  behind. 

consequence  of  the  fact  that  the  right  oblique  diameter  is  longer 
than  the  left. 

Diagnosis. — The  diagnosis  of  vertex  presentation  can  be  made 
by  abdominal  palpation,  vaginal  examination,  and  auscultation. 

Abdominal  Palpation. — The  pelvic  pole  of  the  fcetus  is  found  at 
the  fundus  of  the  uterus,  and  is  distinguished  from  the  cephalic 
pole  by  the  following  signs  : — 

(1)  It  is  less  mobile. 

(2)  There  is  no  groove  or  depression  between  it  and  the  body, 
and  in  some  cases  the  feet  can  be  felt  beside  it. 


THE  DIAGNOSIS  OF  VERTEX  PRESENTATION  307 

(3)  It  is  slightly  larger ;  but  this  sign  is  not  of  much  value 
unless  the  head  is  sufficiently  far  above  the  brim  to  render  it 
possible  to  make  a  comparison. 

(4)  It  is  not  so  hard. 

The  lie  of  the  fcetus  is  found  to  be  longitudinal,  with  the  back 
turned  towards  one  or  other  side,  according  to  the  position.  The 
head  is  found  in  the  lower  pole  of  the  uterus,  if  it  has  not  passed 


Fig.  174  — Site  of  Maximum  Intensity  of  Heart-Sounds  when  the 
Head  is  flexed.     (Bumm.) 

completely  into  the  pelvic  cavity.  It  is  recognised  by  the  fact  that 
it  is  slightly  harder  and  rounder  than  the  breech,  that  there  is  a 
groove  between  it  and  the  body,  and  that  if  it  is  not  fixed  in  the 
brim  it  ballottes  slightly  from  side  to  side.  The  groove  of  the 
neck  lies  obliquely  in  the  uterus,  and  is  lowest  on  the  side  of  the 
foetal  back.  If  the  head  has  passed  in  great  part  into  the  pelvic 
cavity,  the  fingers  can  be  pushed  more  deeply  into  the  cavity  on 
the  side  of  the  back  than  on  the  side  of  the  limbs  (v.  Fig.  173). 


3o8 


THE  PHYSIOLOGY  OF  LABOUR 


Vaginal  Examination. — A  smooth,  rounded  tumour  is  felt  either 
lying  at  the  pelvic  brim  or  in  the  pelvic  cavity,  and  on  it  the 
sutures  and  fontanelles  can  be  recognised.  At  the  commencement 
of  labour,  the  interparietal  suture  corresponds  approximately  to 
one  or  other  oblique  diameter  of  the  pelvis  and  crosses  the  most 
dependent  portion  of  the  presenting  part.  At  either  end  of  the 
suture  the  anterior  and  posterior  fontanelles  can  be  found  lying 


Fig.   175. — The  Mechanism   of   First  Vertex   Presentation. 
The  head  at  the  brim  at  the  commencement  of  labour,  the  vertex  presenting. 


at  approximately  the  same  level,  and  radiating  from  them  their 
respective  sutures.  At  a  later  stage  of  labour,  in  consequence  of 
flexion  and  rotation  of  the  head,  the  posterior  fontanelle  occupies 
a  relatively  deeper  position  in  the  pelvis  than  does  the  anterior 
fontanelle,  and  at  a  still  later  stage,  it  forms  the  presenting  point 
from  which  the  interparietal  and  lambdoidal  sutures  radiate. 
These  points  will  be  more  readily  understood  by  reference  to  the 
accompanying  diagrams. 


THE  MECHANISM  OF  VERTEX  PRESENTATION  309 

The  position  of  the  foetus  is  ascertained  by  noting  the  relation 
of  the  fontanelles  to  the  pelvis.  In  the  first  position,  the  posterior 
fontanelle  lies  in  relation  to  the  left  half  of  the  pelvis,  and  either 
in  front  of  or  behind  the  median  coronal  plane  of  the  pelvis.  In 
the  second  position,  the  posterior  fontanelle  lies  in  relation  to  the 
right  half  of  the  pelvis,  and  either  in  front  of  or  behind  the  same 
plane. 

Auscultation. — The  point  of  maximum  intensity  of  the  foetal 
heart  sounds,  in  cases  of  vertex  presentation,  is  usually  situated 
over  the  back  of  the  foetus,  at  one  or  other  side  of  the  middle  line, 
and  slightly  below  the  level  of  the  umbilicus  (v.  Fig.  174). 

Mechanism. — By  the  term  '  mechanism  of  labour'  is  meant  the 
various  changes  of  attitude  and  position  which  the  foetus  under- 
goes in  order  to  best  adapt  the  different  diameters  of  its  head  and 
body  to  the  different  diameters  of  the  pelvis.  It  is  a  process 
which  it  is  frequently  most  difficult  for  the  student  to  understand, 
and  so  we  shall  devote  a  few  lines  to  trying  to  explain  its 
rationale. 

The  first  point  to  grasp  is  the  necessity  for  a  definite  mechanism. 
If  the  student  recalls  the  various  measurements  of  the  foetal  head 
and  of  the  pelvis,  he  will  find  that  in  order  that  the  head  may 
enter  the  pelvic  brim  it  has  to  lie  in  one  of  several  positions,  in 
order  that  its  diameters  may  be  smaller  than  the  corresponding 
diameters  of  the  pelvis.  When  the  head  lies  at  the  brim  in 
its  normal  attitude,  the  vertex  presenting,  the  occipito-frontal 
diameter  is  the  greatest  engaging  diameter.  It,  however,  measures 
4!  inches,  whereas  by  an  alteration  in  the  attitude  of  the  head 
the  sub-occipito-bregmatic  diameter  can  be  substituted,  which 
measures  only  3-!  inches.  This  substitution  of  a  smaller  diameter 
for  a  greater  is  obtained  by  the  flexion  of  the  head,  and  enables 
the  latter  to  adapt  itself  to  the  outline  of  the  brim.  As,  however, 
the  relation  between  the  antero- posterior  and  the  transverse 
diameters  of  the  pelvis  are  different  at  different  levels  of  the 
pelvis,  so  the  head  will  have  to  alter  its  position  with  regard 
to  the  pelvis  in  order  that  its  greatest  engaging  diameter  may 
always  correspond  to  the  greatest  diameter  of  the  pelvis  at  the 
particular  level  which  it  has  reached.  In  other  words,  at  the 
pelvic  brim  the  transverse  and  oblique  diameters  of  the  pelvis 
are  greater  than  the  conjugate,  while  at  the  outlet  the  reverse  is 
the  case.  Accordingly,  when  the  head  is  passing  through  the 
brim  as  a  vertex  presentation  its  greatest  engaging  diameter — 
i.e.,  the  sub-occipito-bregmatic  diameter — must  lie  in  the  oblique 
or  transverse  diameter  of  the  pelvis,  and  when  it  is  passing 
through  the  outlet  its  sub-occipito-bregmatic  diameter  must  lie 
in  the  antero-posterior  diameter  of  the  outlet.  Similarly,  when 
the  shoulders  are  passing  through  the  brim  their  bis-acromial 
diameter  must  correspond  to  the  oblique  or  transverse  diameter, 
and  when  passing  through  the  outlet  to  the  antero-posterior 
diameter.     The  movement  which  brings  about  this  alteration  in 


3io  THE  PHYSIOLOGY  OF  LABOUR 

the  position  of  the  foetus  is  known  as  a  rotation,  and  we  shall  see 
presently  that  there  are  two  distinct  rotations. 

Further,  the  parturient  canal  is,  as  we  know,  in  the  form  of 
a  curve  with  its  concavity  directed  forwards,  and  in  order  to 
traverse  this  curve  the  head  must  keep  its  long  axis — i.e.,  in 
a  vertex  presentation  its  mento-occipital  diameter — approximately 
in  the  axis  of  the  curve.  Consequently,  whereas  in  passing 
through  the  brim  the  long  axis  of  the  head  points  towards  the 
tip  of  the  coccyx,  as  the  head  descends  it  points  more  and  more 
forwards,  until  as  the  head  is  passing  through  the  outlet  it  lies 
almost  at  right  angles  to  its  former  position.  In  order  that  this 
change  of  direction  may  occur  a  change  in  the  attitude  of  the 
head  is  necessary,  and  this  change  is  brought  about  by  a  gradual 


Fig.  176. — Synclitic  Engagement  of  the  Head. 

movement  of  the  head  from  a  position  of  flexion  to  one  of 
extension. 

We  thus  see  that  in  a  vertex  presentation  the  head  undergoes, 
first,  a  movement  of  flexion,  which  brings  its  smallest  diameters 
into  the  pelvic  brim  ;  then,  a  movement  of  rotation,  which  keeps 
its  greatest  engaging  diameter  in  the  greatest  diameter  of  the 
pelvic  cavity  ;  and,  at  more  or  less  the  same  time,  a  movement 
of  extension,  which  keeps  its  long  axis  in  the  long  axis  of  the 
parturient  canal.  Lastly,  as  the  shoulders  pass  through  the 
pelvis  there  is  another  movement  of  rotation,  in  order  to  keep 
their  bis-acromial  diameters  in  the  greatest  diameters  of  the 
pelvis. 

We  must  now  describe  these  various  movements  systemati- 
cally, but  before  doing  so  we  would  urge  on  the  student  the 
advisability  of  following  them  either  by  means  of  a  comprehensive 


THE  MECHANISM  OF   VERTEX  PRESENTATION 


3" 


series  of  diagrams,  or,  better,  with  a  pelvis  and  mannikin.  If 
the  latter  are  not  at  hand,  a  cast  of  a  fcetal  head  will  answer  most 
purposes. 

The  mechanism  of  a  vertex  presentation  is  usually  described  as 
consisting  of  five  distinct  acts  :— 

(i)  Descent. 

(2)  Flexion. 

(3)  Internal  rotation. 

(4)  Extension. 

(5)  External  rotation. 

It  must  be  clearly  understood  that  the  foregoing  are  not 
distinct  stages  in  the  mechanism  of  labour,  in  that  they  do  not 
regularly  succeed  one  another.  The  act  of  descent  precedes  and 
accompanies  all  the  other  acts,  and  internal  rotation  and  extension 
occur  at  very  much  the  same  time. 

(1)  Descent. — As  we  have  already  seen,  the  force  of  the  uterine 


Fig.  177. — Posterior  Asynclitism  of  the  Head. 


contractions  is  transmitted  to  the  fcetus  in  two  ways.  It  is  trans- 
mitted as  a  '  general  contents  pressure  '  and  as  a  '  fcetal  axis 
pressure '  (v.  Figs.  155-157).  The  former  is  called  into  play  when 
there  is  sufficient  liquor  amnii  round  the  body  of  the  fcetus  to 
prevent  the  fcetus  from  being  directly  pressed  upon  by  the  uterine 
wall,  and  produces  a  force  acting  uniformly  over  the  base  of  the 
skull.  The  latter  comes  into  play  after  the  uterine  wall  has  con- 
tracted down  upon  the  body  of  the  foetus,  and  produces  a  force 
acting  straight  downwards  through  the  axis  of  the  fcetal  body  and 
transmitted  to  the  head  through  the  vertebral  column.  These 
two  forces  bring  about  the  descent  of  the  fcetus.  The  manner  in 
which  the  head  enters  the  pelvis  has  been  the  subject  of  a  con- 
siderable amount  of  discussion.     As  we  know  from  the  study  of 


312 


THE  PHYSIOLOGY  OF  LABOUR 


frozen  sections,  in  a  vertex  presentation  the  head  commences  to 
engage  in  the  brim,  with  its  median  sagittal  plane  corresponding 
to  one  or  other  of  the  oblique  diameters  of  the  brim,  and  with  its 
median  coronal  plane  corresponding  to  the  opposite  oblique 
diameter.  This  position  of  the  head  is  termed  Solayres' 
obliquity."  Further,  the  head  enters  the  brim,  with  its  vertical 
axis  at  right  angles  to  the  plane  of  the  brim.  It  is  not  at  first 
very  obvious  why  the  head  should  enter  the  brim,  with  its  long 
engaging  diameters  corresponding  to  the  oblique  diameters  ;  but 
it  is,  in  all  probability,  due  to  the  pre-existing  position  of  the 
foetus.  In  certain  cases — notably,  of  flat  pelvis,  Solayres' 
obliquity   is    absent,    and    the    head   engages   with    its    antero- 


Fig.  178.— Anterior  Asynclitism  of  the  Head. 


posterior  diameters  corresponding  to  the  transverse  diameter  of 
the  brim. 

The  relation  of  the  long  axis  of  the  head  to  the  plane  of  the 
pelvis  at  the  brim  and  in  the  cavity  has  long  been  the  subject 
of  discussion.  The  head  may  enter  the  brim  in  one  of  three 
ways.  First,  its  long  axis  may  coincide  with  the  axis  of  the 
brim  {v.  Fig.  176).  In  such  a  case,  the  head  is  said  to  engage  in 
a  synclitic  manner,  the  two  parietal  bones  pass  through  the  brim 
simultaneously,  and  the  sagittal  suture  intersects  the  true  con- 
jugate diameter  at  a  point  equidistant  from  the  promontory  and 
the  symphysis.  Secondly,  the  long  axis  of  the  head  may  lie  in 
front  of  the  axis  of  the  brim  (v.  Fig.  177).  In  such  a  case,  the  head 
is  said  to  be  in  a  position  of  posterior  asynclitism,  or  Naegele's 
obliquity.  The  anterior  parietal  bone — i.e.,  the  parietal  bone  in 
relation  to  the  symphysis — is  in  advance  of  the  posterior  parietal 

*  '  Dissertatio  de  partu  viribus  maternis  absolute.'    Paris,  1771. 


THE  MECHANISM  OF  VERTEX  PRESENTATION 


3«3 


bone,  and  the  sagittal  suture  intersects  the  true  conjugate  diameter 
at  a  point  nearer  the  promontory  than  the  symphysis.  Thirdly, 
the  long  axis  of  the  head  may  lie  behind  the  axis  of  the  brim 
(v.  Fig.  178).  In  such  a  case,  the  head  is  said  to  be  in  a  position  ox 
anterior  asynclitism  or  Litzmann's  obliquity — i.e.,  the  posterior 
parietal  bone  is  in  advance  of  the  anterior  parietal  bone,  and  the 
sagittal  suture  intersects  the  true  conjugate  diameter  at  a  point 
nearer  the  symphysis  than  the  promontory.  We  do  not  propose 
to  enter  into  a  discussion  on  this  subject,  as  to  do  so  would  entail 


Fig.  179. — The    Mechanism   of   First   Vertex    Presentation. 
Flexion  is  complete,  and  the  posterior  fontanelle  is  presenting. 


the  devotion  to  it  of  more  space  than  the  practical  importance  ot 
the  question  necessitates.  It  is  sufficient  to  say  that  the  great 
majority  of  observers  are  agreed  that  the  head  passes  through 
the  pelvis  in  a  synclitic  manner,  its  axis  always  more  or  less 
exactly  coinciding  with  the  axis  of  the  pelvic  canal.  Before  the 
fixation  of  the  head  in  the  brim,  many  consider  that  the  head  is 
inclined  on  its  posterior  parietal  bone  (Litzmann's  obliquity),  and 
that  during  the  engagement  of  the  head  this  obliquity  is  corrected.* 
In   certain  cases,  Naegele's  or  Litzmann's  obliquity  may  occur, 

*  Pinard  and  Varnier,  '  Etudes  d'Anatomie  obstetricale  normale  et  patholo- 
gique,'  p.  74. 


314 


THE  PHYSIOLOGY  OF  LABOUR 


just  as  in  certain  cases  Solayres'  obliquity  may  be  absent ;  but 
these  are  all  cases  in  which  the  normal  relation  between  the  size 
of  the  head  and  the  pelvis  is  altered.  They  will  be  referred  to 
subsequently. 

(2)  Flexion. — The  second  act  in  the  mechanism  of  labour  is  the 
completion  of  flexion  of  the  head  (v.  Fig.  1 79).  As  we  already  know, 
the  normal  position  of  the  head  of  the  fcetus  in  the  uterus  is  one  of 
partial  flexion,  and  in  consequence  of  this  the  engaging  diameter 
at  the  commencement  of  labour  is  one  between  the  sub-occipito- 
bregmatic  and  the  occipito-frontal  diameters,  and  the  vertex  is 
the  presenting  part.  As  the  head  passes  through  the  brim,  the 
degree  of  flexion  present  increases.  Two  results  follow  from 
this  : — the  sub-occipito-bregmatic  diameter  becomes  the  engaging 
diameter,  and    the   posterior   fontanelle  becomes  the  presenting 


Fig.  180. — First  Vertex  Presentation. 
The  head  after  flexion  has  occurred,  as  felt  by  vaginal  examination. 

point  (v.  Fig.  180).  The  cause  of  flexion  depends  upon  the  nature 
of  the  force  which  is  acting  upon  the  fetus.  We  have  seen  that 
two  forces  may  act  upon  the  foetus : — one,  the  general  contents 
pressure  acting  equally  over  the  base  of  the  skull ;  the  other,  the 
foetal  axis  pressure  acting  along  the  axis  of  the  foetus,  and 
transmitted  to  the  head,  at  first  through  the  vertebral  column. 
The  explanation  of  the  manner  in  which  the  general  contents 
pressure  causes  flexion  is  somewhat  complex  ;  but  the  expla- 
nation of  flexion,  once  foetal  axis  pressure  has  come  into  existence, 
is  simple. 

Flexion  resulting  from  general  intra- uterine  pressure  alone  is 
due   to  the  shape   of  the  head.      As  we  have  mentioned,  this 


THE  MECHANISM  OF   VERTEX  PRESENTATION 


315 


pressure  acts  as  a  uniform  force  over  the  base  of  the  skull,  and 
so,  if  the  resistance  to  the  descent  of  the  head  was  equal  on  all 
sides,  would  cause  a  simultaneous  descent  of  all  parts  of  the 
head.  Owing  to  the  pre-existing  partial  flexion  of  the  head,  the 
occiput  where  it  meets  with  the  resistance  of  the  brim  is  com- 
paratively sheer,  and  consequently  slips  readily  past  the  brim. 
The  sinciput,  on  the  other  hand,  is  more  prominent  and  tends 
even  to  project  slightly  beyond  the  margin  of  the  brim,  and,  in 
consequence,    there   is    more   or   less   resistance   to   its    descent 


Fig.  181. — Diagram  to  show  the  Method  in  which  Flexion  is  produced 
by  fcetal-axis  pressure  acting  upon  the  head. 

DE,  Line  of  foetal-axis  pressure  ;  AB,  engaging  plane  of  head. 


according  as  the  head  is  large  or  small  in  comparison  with  the 
pelvis.  In  normal  cases,  where  the  antero-posterior  engaging 
diameter  has  almost  sufficient  room  to  pass  easily  through  the 
oblique  diameter,  the  pre-existing  degree  of  flexion  is  but  slightly 
increased.  When,  however,  the  oblique  diameter  of  the  brim  is 
narrowed,  and  when,  consequently,  considerable  obstruction  is 
offered  to  the  engaging  diameter  of  the  head,  flexion  is  exag- 


316  THE  PHYSIOLOGY  OF  LABOUR 

gerated.  In  such  cases,  flexion  may  proceed  so  far  that  the 
occipital  bone  constitutes  the  presenting  part.  This  excessive 
flexion  of  the  head  is  known  as  Roederer's  obliquity. 

The  manner  in  which  foetal  axis  pressure  causes  flexion  is  very 
simple.  The  first  effect  of  the  uterine  contractions,  after  the  liquor 
amnii  has  in  great  part  escaped,  is  to  straighten  out  the  previously 
curved  fcetal  body.  Then,. the  force  of  the  contraction  is  trans- 
mitted to  the  breech,  and  constitutes  a  force  acting  downwards 
through  the  axis  of  the  fcetal  body.  This  force  is  at  first  trans- 
mitted to  the  head  through  the  occipital  condyles,  and  conse- 
quently acts  on  the  base  of  the  skull  at  a  point  nearer  the 
occiput  than  the  sinciput.  Accordingly,  the  occiput  is  driven 
down  until  the  chin  comes  into  contact  with  the  chest.  This 
process  will  be  readily  understood  by  reference  to  the  accom- 
panying diagram  (v.  Fig.  181  ).  The  fcetal  axis  pressure  acting 
along  a  line  DE  acts  on  the  engaging  plane  AB  of  the  head 
at  a  point  C.  Supposing  that  the  resistance  to  the  descent  of 
each  end  of  this  plane  is  equal,  then  as  CB  is  shorter  than  CA, 
the  end  B  of  the  plane  will  tend  to  descend  more  rapidly  than 
the  end  A,  and,  as  DC  is  itself  descending,  flexion  will  con- 
sequently occur.  Further,  as  we  have  seen  that  there  is  less 
resistance  to  the  descent  of  B  than  to  the  descent  of  A,  the 
occiput  will  descend  still  more  rapidly. 

(3)  Internal  Rotation. — As  soon  as  the  advancing  head  has 
reached  the  floor  of  the  pelvis,  the  next  act  in  the  process  of 
labour — that  of  internal  rotation. — commences.  On  the  termina- 
tion of  flexion,  the  head  is  advancing  in  such  a  position  that  its 
small  fontanelle  constitutes  the  presenting  point,  and  its  sub- 
occipito-bregmatic  diameter  corresponds  to  the  oblique  diameter 
of  the  pelvis.  In  consequence  of  the  occurrence  of  internal 
rotation,  the  head  now  commences  to  rotate  round  its  long  axis  in 
such  a  direction  that  the  occiput  moves  forward  from  whatever 
end  of  the  oblique  diameter  it  occupied  until  it  comes  to  lie  in 
the  arch  of  the  pubis.  Consequently,  when  the  movement  is 
complete,  the  antero-posterior  diameter  of  the  head  corresponds 
with  the  antero-posterior  diameter  of  the  outlet  of  the  pelvis 
(v.  Figs.  182,  183). 

The  causes  of  internal  rotation  are  to  be  found  in  the  shape  of 
the  foetal  head,  and  in  the  alteration  which  takes  place  from 
above  downwards  in  the  respective  lengths  of  the  diameters  of 
the  pelvis.  At  the  pelvic  brim,  the  oblique  and  transverse 
diameters  are  greater  than  the  conjugate  ;  but,  at  the  outlet,  the 
antero-posterior  diameter  is  the  greater.  Consequently,  as  there 
is  a  natural  tendency  for  the  large  engaging  diameters  of  the 
head  to  adapt  themselves  to  the  large  diameters  of  the  pelvis,  the 
head  rotates  as  it  descends  in  such  a  manner  as  to  bring  those 
diameters  which  were  in  the  oblique  diameter  of  the  pelvis  into 
the  antero-posterior  diameter.  The  shape  of  the  pelvis  and  the 
resistance  offered  by  the  perinaeum  and  vaginal  walls  are  also 


THE  MECHANISM  OF  VERTEX  PRESENTATION 


317 


important  factors  in  the  production  of  internal  rotation.  If 
either  lateral  half  of  the  bony  pelvis  is  considered  separately,  it 
will  be  seen  that  the  inner  surface  of  the  ischium  resembles  a 
portion  of  a  helix  of  such  a  curve  that  if  a  rounded  body,  such 
as  the  fcetal  head,  is  driven  downwards  through  the  pelvis  with 
sufficient  force,  and  if,  at  the  same  time,  it  is  kept  in  close  apposi- 
tion with  this  inner  surface  or  anterior  inclined  plane  of  the 
ischium,  it  will  be  gently  guided  forwards  until  its  lowest  portion 


Fig.   182. — The  Mechanism  of  First  Vertex  Presentation. 
Internal  rotation  is  complete,  and  the  occiput  lies  behind  the  symphysis. 

comes  to  lie  in  the  pubic  arch.  This  tendency  to  forward  rotation 
is  increased  by  the  fact  that  there  is  less  resistance  to  the  advance 
of  the  presenting  part  under  the  pubic  arch  than  elsewhere,  as  the 
resistance  of  the  vaginal  walls  and  perinaeum  obstruct  its  descent 
posteriorly.  It  is  thus  seen  that  the  movement  of  internal  rotation 
is,  in  fact,  identical  with  the  turning  of  a  screw  in  its  socket, 
the  foetal  head  forming  the  screw,  the  genital  canal  the  socket. 


3i8 


THE  PHYSIOLOGY  OF  LABOUR 


The  length  of  the  turn  depends  upon  the  position  of  the  lowest 
portion  of  the  presenting  part — i.e.,  in  the  case  of  a  vertex  pre- 
sentation the  region  round  the  posterior  fontanelle.  If  the  foetus 
lies  with  its  back  anteriorly — that  is,  with  the  occiput  at  the 
anterior  extremity  of  either  oblique  diameter,  then  internal 
rotation  takes  place  through  one-eighth  of  a  circle.  If,  on  the 
other  hand,  the  occiput  is  in  relation  to  the  posterior  end  of  the 
oblique  diameter,  internal  rotation  takes  place  through  three- 
eighths  of  a  circle.  It  may  be  considered  to  be  a  definite  law 
governing  internal  rotation  that  whatever  part  of  the  presenting 
part  is  lowest  will  rotate  in  front.  In  a  vertex  presentation  under 
normal  circumstances,  the  occipital  end  of  the  head  is  the  lowest, 
and  consequently  it  rotates  forwards.     If,  as  sometimes  happens, 


Fig.  183. — First  Vertex  Presentation. 
The  head  after  internal  rotation  has  occurred,  as  felt  by  vaginal  examination. 


the  sinciput  lies  lowest,  then  internal  rotation  takes  place  in  the 
opposite  direction,  and  the  forehead  is  rotated  forwards. 

The  factors  which  cause  or  assist  in  internal  rotation  of  the 
occiput  may  then  be  summed  up  as  follows  : — 

(a)  The  helical  shape  of  the  internal  surface  of  the  ischium. 

(b)  The  alterations  in  the  respective  length  of  the  diameters  of 
the  pelvis  from  above  downwards. 

(c)  The  fact  that  there  is  less  resistance  offered  to  the  advance 
of  the  head  anteriorly  than  posteriorly. 

(d)  A  foetal  head  of  sufficient  size  to  fill  the  pelvis,  and  a  firm 
resistance  posteriorly  from  the  perinaeum  and  vaginal  walls.  This 
resistance  serves  the  double  purpose  of  preventing  the  posterior 
rotation  of  the  occiput  and  of  maintaining  the  head  in  firm  contact 


THE  MECHANISM  OF  VERTEX  PRESENTATION  319 

with  the  pelvic  wall,  so  ensuring  that  the  rotatory  effect  of  the 
ischial  helix  will  be  produced. 

(e)    A  sufficient  degree  of  flexion  to  bring  the  occiput  lowest. 

(/)  Strong  uterine  contractions  to  drive  the  presenting  part 
onwards. 

(4)  Extension. — The  movement  of  extension  of  the  head  is  the 
opposite  of  flexion,  and  consists  in  a  backward  rotation  of  the 
head  about  a  transverse  axis.  It  commences  as  soon  as  the 
presenting  head  has  reached  the  pelvic  floor,  and  it  continues 
until  the  head  is  born.  Its  effect  is  to  bring  the  head  from  a 
position  of  flexion  to  one  of  extension,  and  so  to  enable  it  to 
follow  the  forward  curve  of  the  genital  canal,  and  to  emerge 
from  the  genital  passages.  The  occiput  of  the  fcetus  appears  at 
the  vulva  and  slowly  distends  the  opening.  The  chin  then 
leaves  the  chest,  and,  as  the  presenting  part  descends,  the  occiput 
advances  until  a  point  about  the  occipital  prominence  comes  to 
lie  beneath  the  symphysis.  This  point  then  fixes  itself  against 
the  symphysis,  and  the  head  rotates  round  it  in  such  a  manner 
that  the  vertex,  the  anterior  fontanelle,  the  brow,  and  the  face 
successively  appear  from  behind  the  perinaeum.  Extension  is 
then  complete. 

The  cause  of  extension  is  very  simple.  The  forces  which  act 
on  the  head  of  the  foetus  are  the  driving  force  of  the  uterus  and 
the  resistance  of  the  perineum  and  of  the  muscles  of  the  pelvic 
floor,  and  their  resultant  is  a  force  acting  along  a  line  which  is 
directed  forwards  and  slightly  downwards.  In  order  that  the 
head  may  move  in  this  direction,  extension  must  take  place.  The 
active  contractions  of  the  levator  ani  muscle  supplement  the 
passive  resistance  of  the  other  structures  of  the  pelvic  floor,  and 
assist  in  driving  the  head  forwards.  This  muscle  has  been  already 
mentioned  as  forming  an  important  part  of  the  pelvic  floor.  In 
its  uncontracted  condition  it  forms  the  concave  sides  of  a  kind 
of  gutter  or  groove,  in  which,  during  a  part  of  the  stage  of 
expulsion,  the  foetal  head  lies.  When  the  muscle  contracts, 
this  groove  becomes  shallower,  and  so  pushes  forward  anything 
which  may  be  lying  in  it.  In  this  manner,  extension  is  brought 
about. 

(5)  External  Rotation. — As  has  been  already  mentioned,  internal 
rotation  brings  the  head  into  such  a  position  that  its  antero- 
posterior diameters  correspond  with  the  antero-posterior  diameters 
of  the  pelvic  outlet,  and  in  this  position  the  head  is  born.  The 
first  movement  which  it  makes  once  it  is  free  from  the  restraint 
of  the  vaginal  walls  and  pelvic  structures  is  one  which  brings  its 
antero-posterior  diameters  again  into  correspondence  with  the 
oblique  diameter  of  the  pelvis  in  which  it  entered  the  brim. 
Then,  as  the  body  of  the  foetus  descends  through  the  pelvis,  the 
head  rotates  a  little  further  in  the  same  direction  until  the  occiput 
points  to  one  or  other  thigh.  These  two  movements  are  generally 
grouped   together    under   the   head   of   external    rotation.      The 


320 


THE  PHYSIOLOGY  OF  LABOUR 


former  of  them  is,  however,  owing  to  its  cause,  more  preferably 
termed  restitution,  inasmuch  as  it  is  caused  by  the  natural 
inclination  of  the  head  to  return  to  its  usual  position  with  regard 
to  the  shoulders.  When  the  head  entered  the  brim  in  one  oblique 
diameter,  the  shoulders  were  lying  above  the  brim  with  their 
bis-acromial  diameter  corresponding  to  the  opposite  oblique 
diameter,  and  in  this  position  they  subsequently  entered  the 
pelvis  as  soon  as  the  head  had  sufficiently  descended  to  permit 


Fig.   184. — Mechanism  of  First  Vertex  Presentation. 
Extension  is  complete  and  the  head  is  born.     Restitution  has  occurred. 

them  to  do  so.  Accordingly,  when  the  head  rotated  into  the 
antero-posterior  diameter  of  the  pelvis,  as  a  result  of  internal 
rotation,  it  became  slightly  twisted  with  regard  to  the  shoulders, 
and,  consequently,  its  first  movement  when  born  is  to  correct  this 
twist,  and  to  return  to  its  correct  position.  This  rotation  of  the 
head  after  its  birth  takes  place  through  one-eighth  of  a  circle, 
and  is  known  as  restitution  (v.  Fig.  184).  The  second  movement 
constitutes   external   rotation    proper,    and    is    the    result    of    the 


THE  MECHANISM  OF   VERTEX  PRESENTATION 


321 


internal  rotation  of  the  shoulders  (v.  Fig.  185).  As  we  have  just 
mentioned,  the  shoulders  pass  through  the  brim  in  the  opposite 
oblique  diameter  to  that  in  which  the  head  traversed  it.  And, 
just  as  in  the  case  of  the  head,  internal  rotation  takes  place  in 
order  to  bring  the  long  diameters  of  the  head  into  relation  with 
the   long    diameters  of   the   outlet,   so   internal    rotation    of   the 


Fig.   185. — Mechanism  of  First  Vertex  Presentation. 
Internal  rotation  has  occurred,  accompanied  by  external  rotation  of  the  head. 


shoulders  takes  place  in  order  to  bring  the  bis-acromial  diameter 
of  the  trunk  into  the  antero-posterior  diameter  of  the  outlet.  The 
manner  in  which  this  rotation  occurs  is  similar  to  that  of  the 
head.  The  shoulder  which  first  reaches  the  pelvic  floor — and  this 
almost  invariably  is  the  anterior  shoulder — rotates  in  front,  and 

21 


322  THE  PHYSIOLOGY  OF  LABOUR 

comes  to  lie  under  the  pubic  arch.  The  head  naturally  follows 
this  internal  rotation  of  the  shoulders,  and,  in  consequence,  rotates 
externally  in  the  same  direction  to  that  in  which  restitution 
occurred,  until  the  occiput  points  to  the  thigh.  External  rotation 
is  then  complete. 

The  Expulsion  of  the  Trunk. — The  trunk,  like  the  head,  observes 
a  definite  mechanism  of  expulsion.  The  shoulders,  as  we  have 
seen,  enter  the  brim  in  the  opposite  oblique  diameter  to  that  in 
which  the  head  entered,  and  traverse  the  pelvis  with  the  anterior 
shoulder  slightly  lower  than  the  posterior.  Internal  rotation  then 
brings  the  bis-acromial  diameter  into  the  antero-posterior  diameter 
of  the  outlet,  and  the  anterior  shoulder  below  the  arch  of  the 
pubes.  Under  this,  it  momentarily  rests,  as  did  the  occiput  in  the 
case  of  the  head,  while  the  posterior  shoulder  pivoting  round  it 
sweeps  over  the  perinaeum  and  is  born.  The  anterior  shoulder 
then  slips  down  also,  and  the  delivery  of  the  shoulders  is  com- 
plete. The  rest  of  the  body  follows,  the  arms  folded  across  the 
chest.  The  hips  undergo  a  similar  rotation  to  the  shoulders, 
and  are  born  with  the  bi-trochanteric  diameter  in  the  antero- 
posterior diameter  of  the  outlet.  As  will  readily  be  seen,  during 
the  expulsion  of  the  trunk  there  is  a  certain  amount  of  latero- 
flexion  and  of  torsion  of  the  body.  Latero-flexion  occurs  in 
consequence  of  the  curve  of  the  genital  canal,  it  is  greatest  at 
the  moment  of  the  expulsion  of  the  shoulders,  and  it  fulfils  in  the 
case  of  the  trunk  the  same  object  that  extension  does  in  the  case 
of  the  head.  Slight  torsion  of  the  body  also  occurs,  as  while  the 
transverse  diameters  of  whatever  part  is  in  the  act  of  passing 
through  the  outlet  lie  in  the  antero-posterior  diameter,  the  trans- 
verse diameters  of  the  part  which  is  passing  through  the  brim  lie 
in  the  oblique.  This  is  similar  to  the  slight  rotation  of  the  head 
on  the  neck  which  occurs  during  internal  rotation,  and  which 
restitution  corrects  immediately  the  head  is  free. 

The  foregoing  general  description  of  the  mechanism  of  labour 
applies  to  any  position  of  the  foetus.  We  shall  now  proceed  to 
describe  the  mechanism  of  each  position  separately. 

First  Position,  Back  to  the  Left. — In  the  first  position,  with  the 
back  in  front — the  first  position  of  Naegele,  or  the  left  occipito- 
anterior— the  foetal  head  enters  the  brim,  with  its  occipito-frontal 
diameter  corresponding  to  the  right  oblique  diameter  of  the  brim, 
the  occiput  anterior,  and  the  bi-parietal  diameter  corresponding 
to  the  left  oblique  diameter.  Flexion  then  occurs,  and  the 
occipito-frontal  diameter  is  replaced  by  the  sub-occipito-bregmatic 
diameter.  The  head  descends,  and  as  soon  as  it  reaches  the 
pelvic  floor  internal  rotation  occurs  and  the  occiput,  which  up 
to  this  lay  at  the  anterior  end  of  the  right  oblique  diameter, 
rotates  anteriorly  and  lies  under  the  pubic  arch.  Extension 
occurs  next,  and  the  brow,  face,  and  chin  sweep  from  behind  the 
perinaeum.  As  soon  as  the  head  is  free,  restitution  takes  place, 
and  the  occiput  turns  back  to  its  former  position.     The  shoulders 


THE  MECHANISM  OF   VERTEX  PRESENTATION  323 

descend  with  their  bis-acromial  diameter  in  the  left  oblique 
diameter  of  the  pelvis,  the  anterior  shoulder  lying  at  a  slightly 
lower  level  than  the  posterior.  As  soon  as  the  pelvic  floor  is 
reached,  the  anterior  shoulder  rotates  forwards  and  lies  in  the 
arch  of  the  pubes.  This  movement  is  accompanied  by  external 
rotation  of  the  head  in  such  a  direction  that  the  occiput  points 
towards  the  left  thigh  of  the  mother.  The  remainder  of  the  body 
is  then  born  as  has  been  described. 

In  the  first  position  with  the  back  behind — the  fourth  position 
of  Naegele,  or  the  left  occipito-posterior — the  head  enters  the  brim 
with  the  occipito-frontal  diameter  corresponding  to  the  left  oblique 
diameter  of  the  pelvis,  the  occiput  posterior  and  the  bi-parietal 
diameter  corresponding  to  the  right  oblique  diameter.  Flexion 
then  occurs,  and  the  occipito-frontal  diameter  is  replaced  by  the 
sub-occipito-bregmatic  diameter.  The  head  descends,  and  as 
soon  as  it  reaches  the  pelvic  floor  the  occiput,  which  up  to  this 
lay  at  the  posterior  end  of  the  left  oblique  diameter,  rotates  in 
front  through  three-eighths  of  a  circle  and  comes  to  lie  under  the 
pubic  arch.  The  shoulders  which  first  lay  in  the  right  oblique 
diameter  of  the  pelvis  follow  this  movement,  and  rotate  first  into 
the  antero-posterior  diameter  and  then  into  the  left  oblique,  in 
which  diameter  they  descend.  Extension  of  the  head  occurs  in 
the  normal  manner.  As  soon  as  the  latter  is  free,  restitution  takes 
place,  and  the  occiput  rotates  to  the  left  through  one-eighth  of  a 
circle.  As  the  shoulders  descend,  the  anterior  shoulder,  which 
lay  at  the  anterior  end  of  the  left  oblique  diameter,  rotates  to 
the  front,  causing  a  corresponding  external  rotation  of  the  head 
towards  the  left  thigh  of  the  mother.  The  shoulders  and  trunk 
are  then  born. 

Second  Position,  Back  to  Right. — In  the  second  position  with  the 
back  in  front — the  second  position  of  Naegele,  or  the  right  occipito- 
anterior— the  head  enters  the  brim,  with  its  occipito-frontal 
diameter  corresponding  to  the  left  oblique  diameter  of  the  brim, 
the  occiput  anterior  and  the  bi-parietal  diameter  corresponding  to 
the  right  oblique  diameter.  Flexion  occurs,  and  the  occipito- 
frontal diameter  is  replaced  by  the  sub-occipito-bregmatic  diameter. 
The  head  then  descends  until  it  reaches  the  pelvic  floor,  when 
internal  rotation  occurs,  and  the  occiput,- which  up  to  this  lay  at 
the  anterior  end  of  the  left  oblique  diameter,  rotates  to  the  front 
and  lies  under  the  pubic  arch.  Extension  takes  place  next,  and 
the  head  is  born.  As  soon  as  the  latter  is  free,  restitution  takes 
place,  and  the  occiput  rotates  to  the  right  through  one-eighth  of  a 
circle.  The  shoulders  descend  in  the  right  oblique  diameter,  the 
anterior  shoulder  lower  than  the  posterior.  As  soon  as  the  pelvic 
floor  is  reached,  the  anterior  shoulder  rotates  in  front,  and  lies 
under  the  pubic  arch,  causing  an  accompanying  external  rotation 
of  the  head  in  such  a  direction  that  the  occiput  points  towards 
the  mother's  right  thigh.  The  shoulders  and  trunk  are  then 
expelled. 

21 — 2 


324  THE  PHYSIOLOGY  OF  LABOUR 

In  the  second  position,  with  the  back  behind — the  third  position 
of  Naegele,  or  the  right  occipito-posterior — the  head  enters  the 
brim  with  the  occipito-frontal  diameter  in  the  right  oblique 
diameter  of  the  brim,  the  occiput  posterior  and  the  bi-parietal 
diameter  corresponding  to  the  left  oblique  diameter.  Flexion 
then  occurs,  and  the  occipito-frontal  diameter  is  replaced  by  the 
sub-occipito-bregmatic  diameter.  The  head  descends,  and  as 
soon  as  it  reaches  the  pelvic  floor  the  occiput,  which  up  to  this 
lay  at  the  posterior  end  of  the  right  oblique  diameter,  rotates 
through  three-eighths  of  a  circle  to  the  front  and  lies  under  the 
pubic  arch.  The  shoulders,  which  first  lay  in  the  left  oblique 
diameter,  accompany  this  movement,  and  rotate  first  into  the 
antero-posterior  diameter,  and  then  into  the  right  oblique,  in 
which  diameter  they  descend.  Extension  of  the  head  occurs  in 
the  usual  manner.  As  soon  as  it  is  free,  restitution  occurs,  and 
the  occiput  turns  through  one-eighth  of  a  circle  to  the  right. 
As  the  shoulders  descend,  the  anterior  shoulder,  which  lay  at  the 
anterior  end  of  the  right  oblique  diameter,  rotates  to  the  front, 
causing  a  corresponding  external  rotation  of  the  head  towards  the 
mother's  right  thigh.     The  shoulders  and  trunk  are  then  born. 

Abnormalities  of  Mechanism  in  Vertex  Presentation. — Various  ab- 
normalities in  mechanism  occur,  some  of  which  are  of  practical 
importance,  while  others  are  merely  matters  of  interest. 

Hyper-rotation  of  the  Head. — In  a  very  small  proportion  of  cases 
in  which  the  foetus  lies  in  either  the  first  or  the  second  position 
with  the  back  anterior,  the  head  may  rotate  too  far,  and  so 
instead  of  passing  from  a  position  in  which  the  sub-occipito- 
bregmatic  diameter  corresponded  to  the  oblique  diameter  of  the 
pelvis  to  one  in  which  it  corresponds  to  the  antero-posterior, 
rotation  continues  until  this  diameter  of  the  head  comes  to  corre- 
spond to  the  opposite  oblique  diameter  to  that  from  which  it 
started.  In  such  cases,  the  head  is  expelled  with  the  occiput 
fixed  under  one  or  other  ramus  of  the  pubis  instead  of  under  the 
pubic  arch.  It  is  not  an  anomaly  which  interferes  to  any  great 
extent  with  the  progress  of  labour. 

Reversed  Rotation  of  the  Shoulders. — As  a  rule,  the.  anterior 
shoulder  lies  slightly  lower  than  the  posterior,  and  consequently,  in 
obedience  to  the  principle  which  governs  internal  rotation,  rotates 
forwards  during  the  birth  of  the  trunk.  Occasionally,  however, 
it  happens  that  the  posterior  shoulder  lies  lowest,  and  so  rotates 
forwards,  travelling  through  three-eighths  of  a  circle  instead  of 
one-eighth.  In  such  a  case,  external  rotation  of  the  head  also 
occurs  in  the  opposite  direction  to  the  usual  one.  In  a  first 
position,  instead  of  external  rotation,  bringing  the  occiput  back 
through  one-eighth  of  a  circle  to  the  side  from  which  it  started, 
it  brings  the  occiput  round  through  three-eighths  of  a  circle  to 
point  towards  the  opposite  side.  This  abnormality  does  not  affect 
the  progress  of  labour  to  any  important  extent. 

Reversed  Rotation  of  the  Head — Persistent  Occipito-Posterior 


REVERSED  ROTATION  OF  THE  HEAD 


325 


Position. — This  is,  perhaps,  the  most  common  and  important 
abnormality  in  the  mechanism  of  vertex  presentations,  and  is 
said  to  occur  in  1*9  per  cent,  of  cases  of  this  presentation.  We 
have  already  drawn  attention  to  the  principle  which  governs 
intrapelvic  rotation  : — whatever  part  of  the  foetus  lies  lowest, 
and  so  first  reaches  the  pelvic  floor,  rotates  in  front.  As  a  rule, 
in  vertex  presentation  the  occiput  lies  at  a  lower  level  in  the 
pelvis  than  the  sinciput,  and  consequently  rotates  forwards, 
even  in  cases  where  it  was  posterior  at  the  commencement.  In 
a  small  proportion  of  cases,  however,  in  which  the  back  was 
posterior  at  the  commencement,  it  happens  that  flexion  is  not 
complete,  and  that,  consequently,  the  sinciput  is  as  low  as,  or, 


Fig.   186. — Reversed  Rotation  of  the  Head. 

The  head  after  internal  rotation  has  occurred  and  the  occiput  rotated  into  the 
hollow  of  the  sacrum. 


perhaps,  even  a  little  lower  than,  the  occiput.  In  consequence  of 
this,  the  sinciput  tends  to  rotate  forwards,  the  face  lying  behind 
the  pubis,  and  the  occiput  is  carried  into  the  hollow  of  the 
sacrum  (v.  Fig.  186). 

Incomplete  flexion  of  the  head,  and  hence  posterior  rotation 
of  the  occiput,  is  more  common  in  cases  in  which  the  occiput 
was  primarily  directed  backwards.  It  must  not,  however,  be 
supposed  that  original  occipito-anterior  positions  never  rotate 
posteriorly.  From  the  statistics  of  the  Baudelocque  Hospital,  we 
learn  that  amongst  8,007  patients  posterior  rotation  of  the  occiput 
occurred  44  times;  and  of  these  44  cases,  in  17  was  the 
occiput  primarily  anterior;  in  27,  primarily  posterior  (Ribemont- 
Dessaignes).     It  may  be  asked,  Why  should  there  be  a  greater 


326  THE  PHYSIOLOGY  OF  LABOUR 

tendency  for  incomplete  flexion  in  cases  of  primary  posterior 
position  of  the  occiput  than  there  is  in  cases  of  primary  anterior 
position  ?  This  is  very  concisely  explained  by  Herman  *  as 
follows : — In  the  first  place,  the  axis  of  the  upper  portion  of  the 
utero-pelvic  canal  is  concave  backwards.  If  the  foetus  lies  with 
its  back  in  front,  then  the  natural  semi-flexed  position  of  its  body 
enables  it  to  so  accommodate  its  abdominal  surface  to  the  con- 
vexity of  the  spinal  column,  that  the  head  can  pass  through  the 
brim  in  a  position  of  full  flexion.  If,  however,  the  back  of  the 
foetus  is  directed  posteriorly,  then  a  certain  degree  of  diminished 
flexion  or  of  commencing  extension  must  take  place  in  order  to 
allow  the  head  to  pass  through  the  brim.  In  the  second  place, 
when  the  head  enters  the  brim  with  the  occiput  anterior,  the 
bi-parietal  diameter  almost  exactly  corresponds  with  one  or  other 
oblique  diameter  of  the  pelvis,  where  there  is  sufficient  space  for 
it.  If,  however,  the  occiput  is  directed  posteriorly,  then  the  bi- 
parietal  diameter  has  to  fit  into  a  diameter  of  the  pelvis,  which  is 
posterior  to,  and  smaller  than,  the  oblique  diameter.  In  conse- 
quence, the  descent  of  the  occiput  is  retarded,  and  a  varying  degree 
of  extension  may  be  produced,  particularly  in  the  case  of  a  large 
foetus.  In  such  cases,  the  further  mechanism  of  delivery  is  altered, 
and  the  head  may  be  expelled  in  one  of  the  following  ways.  The 
sinciput  may  be  the  first  part  of  the  head  to  appear.  Then  the 
root  of  the  nose  fixes  beneath  the  symphysis,  and,  the  head 
pivoting  on  this  point  by  a  slight  movement  of  flexion,  the 
vertex  and  occiput  in  turn  appear  from  behind  the  perinaeum. 
As  soon  as  the  latter  is  born,  a  slight  movement  of  extension 
takes  place  and  the  face  descends  from  behind  the  pubis.  In  the 
alternative  manner  of  birth,  the  head  flexes  so  that  the  forehead 
slips  up  behind  the  symphysis,  and  then,  the  head  pivoting 
around  it,  the  vertex  and  occiput  are  born  as  before  by  flexion. 
Finally,  a  movement  of  extension  occurs,  and  the  sinciput,  the 
face,  and  the  chin  appear  from  behind  the  symphysis. 

In  these  cases  of  reversed  internal  rotation  of  the  head,  external 
rotation  is  also  affected,  and  the  occiput  rotates  from  behind 
forwards  until  it  points  to  the  thigh  corresponding  to  the  side  at 
which  it  originally  lay. 

All  cases  of  occipito-posterior  position  of  the  vertex,  whether 
subsequently  corrected  by  anterior  rotation  or  not,  are  more 
tedious  than  anterior  positions.  On  an  average,  labour  lasts  from 
two  hours  to  three  hours  and  a  half  longer  in  the  case  of  primi- 
parse,  and  from  one  hour  to  one  hour  and  a  half  longer  in  the 
case  of  multiparas,  than  in  the  case  of  anterior  positions.!  This 
delay  is  said  by  Varnier  to  occur  more  during  the  stage  of  dilata- 
tion than  of  expulsion,  but  our  own  experience  would  lead  us  to 
the  opposite  opinion.  The  proportion  of  cases  in  which  spon- 
taneous delivery  occurs   is   not,  however,  very  much   less.     In 

*  'Difficult  Labour,'  1901  edition,  p.  4. 

■f  Ribemont-Dessaignes  and  Lepage,  op.  cit.,  p.  302. 


POSTERIOR  ASYNCLITISM  327 

anterior  positions  spontaneous  delivery  is  said  to  occur  in  94  per 
cent,  of  cases,  and  in  posterior  positions  in  90  per  cent. 

Lateral  Obliquity  of  the  Head. — We  have  already  mentioned 
that  the  vertex  may  traverse  the  brim  in  one  of  three  positions,  so 
far  as  the  relation  between  its  long  axis  and  the  axis  of  the  brim 
is  concerned.  In  the  first  place,  the  long  axis  of  the  head 
coincides  with  the  axis  of  the  brim,  the  two  parietal  bones  pass 
through  the  brim  simultaneously,  and  the  sagittal  suture  inter- 
sects the  true  conjugate  at  a  part  equidistant  from  the  symphysis 
and  the  promontory.  This  is  known  as  synclitic  engagement  of 
the  head,  and  is  the  normal  condition.  In  the  second  place,  the 
long  axis  of  the  head  is  inclined  in  front  of  the  axis  of  the  brim, 
the  anterior  parietal  bone  traverses  the  brim  in  advance  of  the 
posterior,  and  the  sagittal  suture  intersects  the  true  conjugate  at  a 
point  nearer  the  promontory  than  the  symphysis.  This  is  known 
as  posterior  asynclitism  of  the  head  or  Naegele's  obliquity.  In  the 
third  place,  the  long  axis  of  the  head  is  inclined  behind  the  axis 
of  the  brim,  the  posterior  parietal  bone  traverses  the  brim  in 
advance  of  the  anterior,  and  the  sagittal  suture  intersects  the 
true  conjugate  at  a  point  nearer  the  symphysis  than  the  pro- 
montory. This  is  known  as  anterior  asynclitism  of  the  head,  or 
Litzmann's  obliquity.  We  have  already  dealt  with  synclitic 
engagement  of  the  head — the  normal  condition,  and  we  must 
now  deal  with  the  other  two. 

Posterior  Asynclitism.  —  Posterior  asynclitism  of  the  head — 
Naegele's  obliquity"  or  anterior  parietal  presentation — is  the 
result  of  such  a  disproportion  between  the  size  of  the  head  and  the 
pelvis,  that  while  there  is  room  in  the  transverse  diameter  of  the 
pelvis  for  the  antero-posterior  diameters  of  the  head,  a  narrowing 
of  the  antero-posterior  diameters  of  the  pelvis  prevents  the  descent 
of  the  transverse  diameters  of  the  head.  As  is  obvious,  such  a 
condition  is  found  in  cases  of  flat  pelvis  where  the  transverse 
diameter  of  the  pelvis  is  normal,  or  almost  so,  but  the  conjugate 
is  narrowed  by  the  projection  of  the  promontory.  In  such  cases, 
the  head  enters  the  brim  with  the  occipito-frontal  diameter  corre- 
sponding to  the  transverse  diameter  of  the  brim.  The  descent 
of  the  posterior  parietal  bone  is  prevented  by  the  projecting  pro- 
montory, and,  the  head  rotating  on  its  antero-posterior  diameter, 
the  anterior  parietal  bone  descends  while  the  posterior  remains 
fixed  or  even  moves  slightly  upwards.  In  consequence,  the  sagittal 
suture  approaches  the  promontory  (v.  Fig.  187).  The  greater  the 
obstruction  to  the  descent  of  the  posterior  parietal  bone,  the 
further  does  this  rotation  continue,  and  in  cases  of  marked  obstruc- 
tion the  sagittal  suture  may  reach  the  promontory,  and  the  ear  be 
found  behind  the  symphysis  (ear  presentation).  Consequently, 
a  very  reliable  estimate  of  the  degree  of  obstruction  present  may 
be  made  by  noting  the  position  of  the  sagittal  suture  (Litzmann). 
If  the  obstruction  is  not  too  great  for  the  head  to  pass  the  brim, 
*  '  Die  Lehre  vom  Mechanismus  der  Geburt.'     Mainz,  1838. 


328 


THE  PHYSIOLOGY  OF  LABOUR 


the  anterior  parietal  bone  becomes  fixed  behind  the  symphysis, 
and  the  head  rotating  round  it,  the  posterior  parietal  bone  is 
squeezed  past  the  promontory.  At  the  same  time  the  head,  as 
a  whole,  glides  transversely  in  the  direction  of  the  occiput,  and 
so  brings  a  diameter  between  the  bi-parietal  and  the  bi-temporal 
diameters  into  the  conjugate.  In  consequence  of  these  two  move- 
ments, and  of  the  crushing  of  the  parietal  bone  against  the 
promontory,  a  deep  dint  may  occur  in  the  head  where  it  was  in 
contact  with  the  promontory.  As  soon  as  the  parietal  bone  has 
passed  the  promontory,  the  remainder  of  the  mechanism  of 
delivery  is  as  usual. 

The  causes  of  posterior  asynclitism,  in  cases  in  which  there  is 


Fig.    187. — Posterior    Asynclitism,     or    Naegele's    Obliquity. 
The  head  presenting  at  the  brim,  as  felt  by  vaginal  examination. 

no  disproportion  between  the  size  of  the  head  and  of  the  pelvis, 
are  to  be  found  in  a  pendulous  abdomen  and  latero-flexion  of  the 
body  of  the  foetus.  In  a  pendulous  abdomen  the  axis  of  the 
uterus  lies  considerably  in  front  of  the  axis  of  the  brim,  and, 
consequently,  the  head,  instead  of  being  driven  down  into  the 
pelvis,  is  driven  more  or  less  in  the  direction  of  the  promontory. 
As  a  result,  the  anterior  parietal  bone  presents,  owing  to  the 
horizontal  position  of  the  foetus  and  to  the  obstruction  offered  to 
the  descent  of  the  posterior  parietal  bone.  Latero-flexion  of  the 
body  of  the  foetus,  in  such  a  direction  as  to  carry  the  head  more 
posteriorly  than  usual,  also  tends  to  produce  this  condition. 

Anterior  Asynclitism.  —  Anterior  asynclitism  of  the  head — 
Litzmann's  obliquity,*  or  reversed  Naegele's  obliquity,  or  posterior 

*  '  Ueber  die  hintere  Scheitelbeineinstellung,'  Archiv  f.  Gyn.,  1871,  ii. 
433-41°- 


ANTERIOR  ASYNCLITISM 


329 


parietal  presentation-  -is  a  rarer  abnormality  of  labour  than  the 
previous  condition.  It  is  met  with  in  both  contracted  and  non- 
contracted  pelves,  and  is  probably  more  frequently  met  with  in 
association  with  a  normal  pelvis  than  is  posterior  asynclitism 
(Winckel).  It  is  difficult  to  determine  its  precise  cause,  but,  in 
all  probability,  alterations  in  the  normal  relation  between  the 
uterus  and  of  the  pelvic  brim  are  largely  concerned  in  its  produc- 
tion. If  the  axis  of  the  uterus  lies  posterior  to  the  axis  of  the 
pelvic  brim,  then  the  uterine  contractions  drive  the  head  more 
forcibly  against  the  symphysis  than  is  normally  the  case.  As 
a  result,  the  descent  of  the  anterior  parietal  bone  is  obstructed 
and  the  posterior  becomes  the  presenting  part.  This  condition 
may  also  occur  in  flattened  pelves  and  in  cases  of  latero-flexion 


Fig.    188. — Anterior   Asynclitism,    or    Litzmann's    Obliquity. 
The  head  presenting  at  the  brim,  as  felt  by  vaginal  examination. 

of  the  body  of  the  fcetus  in  which  the  head  is  carried  more 
anteriorly  than  normal.  If  the  obstruction  to  the  descent  of  the 
anterior  parietal  bone  is  so  great  as  to  prevent  the  passage  of  the 
head  through  the  brim,  the  head  continues  to  rotate  on  its  antero- 
posterior diameter,  and,  consequently,  the  sagittal  suture  ap- 
proaches nearer  and  nearer  to  the  symphysis  (v.  Fig.  188).  If 
this  rotation  continues  long  enough,  the  ear  may  present.  The 
manner  in  which  the  head  passes  through  the  brim  in  a  flat  pelvis 
with  this  obliquity  present  is  thus  described  by  Herman  : — '  The 
pains  drive  down  the  anterior  parietal  bone,  and,  as  it  descends, 
the  posterior  lying  parietal  bone  moves  up,  and  then  first  the 
anterior  parietal  eminence  passes  the  brim,  then  the  posterior. 
Sometimes  the  side  of  the  head  opposite  the  promontory  remains 


33o 


THE  PHYSIOLOGY  OF  LABOUR 


fixed,  and  the  head  rotates  round  this  point  as  when  it  is  in  the 
anterior  parietal  position  it  rotates  round  the  symphysis.  But 
this  only  happens  when  the  foetal  head  is  small  and  soft,  so  that  it 


St-0 


Fig.  i8g.  — The  Moulding  of  the  Head  in  Vertex  Presentation. 
The  black  outline  shows  the  unmoulded,  the  red  the  moulded,  head.    (Budin.) 


St  0 


Fig.  igo. — The  Usual  Moulding  of  the  Head  in  Occipito-Posterior 
Positions  of  the  Vertex.     (Galabin. ) 


becomes  indented  instead  of  moving  up.':;:     Anterior  asynclitism 
of  the  head  is  always  unfavourable  to  delivery,  and  in  this  way 

*  Op.  cit.,  p.  185. 


THE  MOULDING  OF  THE  HEAD  331 

contrasts  with  posterior  asynclitism,  which  is  the  most  favourable 
mechanism  of  delivery  in  cases  of  fiat  pelvis. 

Moulding. — The  pressure  to  which  the  head  is  subjected  during 
labour  in  consequence  of  the  rigidity  of  the  pelvis,  results,  in 
the  case  of  a  vertex  presentation,  in  a  considerable  change  in 
the  form  of  the  head.  The  occipito-frontal,  the  sub-occipito-breg- 
matic,  and  the  bi-parietal  diameters  are  all  diminished,  while  the 
necessary  compensatory  elongation  is  obtained  by  a  considerable 
increase  in  the  supra-occipito-mental  diameter.  These  alterations 
produce  a  marked  effect  upon  the  shape  of  the  head,  which  is 
well  shown  in  the  accompanying  diagram  (v.  Fig.  189).  In  cases 
of  occipito-posterior  rotation  of  the  head,  the  moulding  which 
takes  place  is  somewhat  different.  It  will  be  remembered  that  we 
described  two  methods  in  which  the  head  could  be  born  in  this 
position.  In  the  first,  the  root  of  the  nose  comes  to  lie  under  the 
symphysis,  the  sinciput  is  born  first,  then  the  vertex  and  occiput 
by  flexion,  and,  finally,  the  face  by  extension.  In  this  case  the 
moulding  of  the  head  results  in  a  marked  diminution  in  the 
occipito-frontal  and  occipito-mental  diameters,  and  a  compensa- 
tory increase  in  the  sub-occipito-bregmatic  and  in  the  cervico- 
bregmatic  diameters  (v.  Fig.  190).  In  the  second  method  of 
delivery,  extreme  flexion  brings  the  forehead  behind  the  sym- 
physis ;  the  occiput  is  first  born  by  a  slight  increase  of  flexion, 
and  the  remainder  of  the  head  by  extension.  In  such  cases, 
the.  moulding  of  the  head  results  in  the  production  of  a  more 
marked  degree  of  the  same  changes  as  occur  in  the  normal  vertex 
mechanism.  The  sub-occipito-bregmatic  and  the  sub-occipito- 
frontal  diameters  are  very  much  diminished,  while  the  com- 
pensatory elongation  of  the  supra-occipito-mental  diameter  is 
considerable. 

The  caput  succedaneum,  as  a  rule,  first  forms  about  the  centre 
of  the  interparietal  suture,  and  to  the  right  or  left  of  it  according 
as  the  foetus  lies  in  a  first  or  second  position.  As  flexion  and 
rotation  occur,  and  the  head  descends,  the  caput  moves  back- 
wards along  the  edge  of  the  suture  in  the  direction  of  the  posterior 
fontanelle.  In  cases  of  occipito-posterior  rotation  of  the  head, 
the  caput  forms  over  the  anterior  superior  angle  of  one  or  other 
parietal  bone,  according  to  the  position  in  which  the  foetus  lies, 
and  does  not  materially  change  its  position  during  expulsion.  As 
the  caput,  as  a  general  rule,  is  situated  more  on  the  right  side  of 
the  head  in  a  first  position  and  on  the  left  side  in  a  second  position, 
it  is  usually  possible  to  determine  after  expulsion  of  the  foetus  the 
position  in  which  it  lay,  and  so  to  correct  our  original  diagnosis. 


CHAPTER  IV 
THE  MANAGEMENT  OF  NORMAL  LABOUR 

Preparations  for  Labour — Posture  in  Obstetrical  Practice;  The  Side  Position, 
The  Dorsal  Position,  The  Knee-chest  Position,  Trendelenburg's  Posi- 
tion, Walcher's  Position — The  Management  of  the  First  Stage — The 
Management  of  the  Second  Stage,  The  Treatment  of  Occipito-posterior 
Positions  of  the  Head — The  Management  of  the  Third  Stage — The 
Management  of  the  Infant — Anaesthesia  during  Labour — The  Use  of 
Ergot. 

Normal  labour  consists  in  the  child  presenting  by  its  vertex,  and 
in  the  uterine  contractions  coming  on  and  following  one  another  in 
such  a  manner  that  the  child  is  born  and  labour  is  ended  without 
artificial  aid  or  any  complications  within  twenty-four  hours.  About 
90  per  cent,  of  all  labours-follow  such  a  course,  and,  consequently, 
it  is  of  the  greatest  importance  that  the  obstetrician  should  under- 
stand the  phenomena  and  management  of  normal  labour.  The 
golden  rule  to  remember  is  that  so  long  as  events  are  following 
a  normal  course  the  patient  requires  but  little  assistance.  The 
obstetrician  must  be  capable  of  detecting  any  deviation  from  the 
normal  course  of  events  and  of  remedying  it,  and  he  must  also  be 
capable  of  refraining  from  interference  so  long  as  their  course 
remains  normal.  All  internal  manipulations  impart  an  extra 
element  of  risk  to  the  labour,  and  hence  they  must  only  be  made 
to  guard  against  or  remove  greater  risks. 

Preparation  for  Labour. — The  room  in  which  the  patient  is  to  be 
confined,  and  in  which  she  must  subsequently  pass  the  puerperium, 
should  be,  whenever  possible,  of  good  size,  well  ventilated,  warm, 
well-lit,  and  free  from  draughts  and  from  unnecessary  furniture. 
The  patient's  bed  must  be  so  placed  that  plenty  of  light  may  fall 
on  it,  especially  on  the  right-hand  side.  It  should  stand  on  a  large 
piece  of  linoleum  in  order  to  prevent  blood  or  other  fluid  from 
falling  on  the  carpet.  The  bedstead  should  be  a  single  one,  made 
of  metal,  and  with  a  wire  mattress,  on  which  a  firm  hair  mattress 
is  placed.  If  possible,  it  is  advisable  that  during  the  confinement 
boards  should  be  placed  between  the  hair  mattress  and  the  wire 
one  in  order  to  make  the  former  as  steady  as  possible,  as  it  is 
most  difficult  to  maintain  the  patient  in  either  the  lateral  or  the 
cross-bed  position  if  the  edge  of  the  bed  sags  beneath  her  weight. 

332 


PREPARATION  FOR  LABOUR  333 

These  boards  can  be  removed  as  soon  as  labour  is  over.  The 
bed  itself  should  be  made  in  the  following  manner  from  below 
upwards: — (1)  The  mattress  ;  (2)  A  large  mackintosh  completely 
covering  the  mattress  and  turned  in  beneath  it ;  (3)  An  under 
blanket ;  (4)  The  under  sheet  and  bolster ;  (5)  A  small  mackintosh 
enclosed  in  a  draw-sheet,  of  sufficient  size  to  reach  from  the 
middle  of  the  patient's  back  to  the  knees ;  (6)  A  pillow  ;  (7)  A 
top  sheet  and  the  necessary  number  of  blankets.  The  draw-sheet 
and  contained  mackintosh  should  hang  over  the  side  of  the  bed 
in  such  a  manner  as  to  form  a  valance.  The  other  essentials  in 
the  room  are  a  large  jug  which  will  hold  about  a  gallon  and 
a  half;  a  stand  on  which  it  can  be  placed  and  which  will  raise  it 
about  two  feet  above  the  bed  of  the  patient  ;  four  basins — one  in 
which  to  wash  the  hands,  one  for  the  antiseptic,  one  in  which  to 
keep  cotton-wool  wipes  for  the  patient,  and  one  in  which  to  place 
any  instruments  that  may  be  required  ;  plenty  of  hot  and  cold 
water,  a  small  bath  in  which  the  infant  can  be  washed  ;  a  large 
bath  or  tin  to  place  beneath  the  bed,  if  douching  is  required ; 
lastly,  a  fire  on  which  a  kettle  can  be  boiled  should  be  within 
reach,  in  cold  weather  it  will  be  in  the  patient's  room.  The 
jugs  for  the  douche,  and  all  the  basins,  must  be  carefully  scrubbed 
with  soap  and  water  before  use.  The  garments  for  the  infant, 
and  the  patient's  binder,  etc.,  should  be  hung  near  the  fire  so  that 
they  may  be  warm  when  required.  The  sanitary  towel  or  wool 
pad  which  it  is  intended  to  apply  over  the  vulva  after  delivery, 
and  the  ligatures  with  which  it  is  intended  to  tie  the  cord  should 
be  placed  at  the  commencement  of  labour  in  a  basin  in  1  in  500 
corrosive  sublimate  or  other  disinfectant.  By  so  doing,  they  are 
sterilised  ready  for  use  when  required. 

The  patient  should  be  clad  in  warm,  light,  and  loose  garments 
which  can  readily  be  removed  when  necessary.  During  the  first 
stage,  she  may  wear  her  usual  underclothing  covered  by  a 
dressing-gown.  During  the  second  stage,  when  she  is  in  bed,  a 
short  night-gown  and  a  flannel  wrapper  are  best.  A  clean  night- 
gown must  be  ready  for  use  after  delivery. 

It  is  advisable  in  all  cases  to  administer  a  purgative  as  soon  as 
the  first  symptoms  of  labour  appear.  For  this  purpose  castor-oil, 
liquorice-powder,  or  cascara  sagrada  may  be  used,  and  should  be 
followed  by  an  enema  as  soon  as  labour  has  well  set  in.  In  this 
way  the  rectum  is  emptied,  and  all  soiling  of  the  parts  by  the 
forcing  out  of  faeces  during  the  second  stage  is  avoided.  The 
patient  should  pass  water  at  frequent  intervals  during  labour,  and 
if  she  is  unable  to  do  so  a  catheter  must  be  passed.  It  is  also 
a  good  thing  for  the  patient  to  have  a  warm  bath  during  the 
premonitory  stage,  but  the  nurse  must  be  in  the  room  at  the  time 
to  assist  her.  Cases  of  precipitate  labour,  in  which  the  child  was 
born  unexpectedly  while  the  patient  was  in  a  bath,  have  been 
recorded.  In  all  cases,  the  external  genitals  must  be  well  washed 
by  the  nurse  with  soap  and  water  and  then  bathed  with  an  un- 


334  THE  PHYSIOLOGY  OF  LABOUR 

irritating  antiseptic.  For  this  purpose  lysol  is  most  suitable,  but 
it  must  not  be  used  too  strong  or  it  will  cause  smarting.  The  use 
of  corrosive  sublimate  for  this  purpose  during  labour  is  contra- 
indicated,  as  it  constringes  the  parts,  and  so  makes  them  prone  to 
lacerate.  Vaginal  douches  should  not  be  administered  in  cases 
of  normal  labour,  unless  they  are  indicated  by  the  presence  of 
a  pathological  condition  of  the  genital  canal. 

Posture  in  Obstetrical  Practice. — There  are  several 
different  postures  or  positions  in  which  the  patient  can  be  placed 
during  labour,  and  which  offer  special  advantages  under  particular 
circumstances.  The  principal  of  these  various  positions  are  as 
follows : — 

(i)  The  side  position.  (2)  The  cross-bed  position.  (3)  The 
knee-breast  position.  (4)  Trendelenburg's  position.  (5)  Walcher's 
position. 

The  Side  Position. — The  choice  of  the  side  on  which  the  patient 
shall  lie  is  governed  by  the  conditions  present.  In  these  countries, 
unless  there  is  any  special  indication  for  any  other  position,  the 
patient  lies  during  the  second  stage  on  the  left  side,  her  buttocks 
projecting  over  the  edge  of  the  bed,  and  her  knees  slightly  drawn 
up.  She  is  then  in  the  most  suitable  position  for  a  vaginal 
examination,  and  during  delivery  the  operator,  standing  behind 
her  at  the  level  of  the  sacrum  and  facing  her  feet,  has  his  right 
hand  free  to  undertake  the  necessary  manoeuvres  for  the  preserva- 
tion of  the  perinaeum.  On  the  other  hand,  anomalies  in  the  mode 
of  presentation  of  the  head  at  the  brim  or  of  the  presentation 
may  necessitate  in  some  cases  a  change  of  position,  as  the  side  on 
which  the  patient  lies  influences  to  some  extent  the  relation  of 
the  presenting  part  to  the  pelvic  brim  and  the  course  of  internal 
rotation.  When  the  patient  lies  on  one  side,  the  body  of  the 
foetus  falls  over  to  the  same  side,  and  the  presenting  part,  if  not 
fixed,  rises  towards  the  opposite  side.  Accordingly,  if  the  foetus 
is  lying  in  an  oblique  position  with  its  presenting  pole  in  one  iliac 
fossa  instead  of  over  the  brim,  by  placing  the  patient  on  the  side 
at  which  the  presenting  pole  lies,  we  help  the  latter  to  rise  out  of 
that  position  and  to  come  to  lie  over  the  brim.  Similarly,  if  the 
presenting  part  is  in  the  brim,  and  if  we  desire  to  lessen  its 
pressure  against  one  side  of  the  brim,  as  in  the  case  of  a  pro- 
lapse or  presentation  of  the  cord,  we  place  the  patient  on  the 
side  at  which  the  prolapsed  cord  lies,  in  order  that  the  presenting 
part  may  rise  slightly  towards  the  opposite  side.  Furthermore,  it 
is  advisable  that  in  a  vertex  presentation  the  patient  should  lie 
on  the  side  to  which  the  occiput  is  turned,  and  in  a  face  presenta- 
tion on  the  side  to  which  the  chin  is  turned,  as  this  is  said  to 
favour  their  anterior  rotation. 

The  Dorsal  Position. — In  the  dorsal  position,  the  patient  lies  on 
her  back,  the  head  and  shoulders  low,  the  hips  slightly  raised, 
and  the  lower  limbs  drawn  up  and  separated,  so  that  the  heels 


THE  KNEE-CIIEST  POSITION 


335 


rest  firmly  upon  the  bed  near  the  thighs.  The  dorsal  position  is 
usually  adopted  in  preference  to  the  lateral  position,  on  the 
Continent  and  in  America,  during  the  delivery  of  the  infant. 
Its  chief  advantage  is  that  auscultation  can  be  more  readily 
performed  at  any  moment  without  changing  the  position  of  the 
patient — an  important  consideration  during  the  expulsion  of  the 
fcetus.  Whatever  may  be  its  merits  in  the  second  stage,  there 
can  be  no  doubt  that — as  will  be  presently  seen — it  is  the  most 
advantageous  position  in  which  to  place  the  patient  during  the 
third  stage.  In  the  dorsal  cross-bed  position,  the  patient  lies  on 
her  back  across  the  bed,  with  her  buttocks  projecting  over  the 
edge  (v.  Fig.  191),  and  her  legs  supported  by  an  assistant  at  each 
side,  or  resting  on  specially  made  leg-rests.     It  is  the  position 


Fig.  191. — The  Dorsal  Cross-Bed  Position. 

usually  adopted  in  all  obstetrical  operations,  save,  perhaps,  the 
application  of  the  forceps. 

The  Knee-Chest  Position. — In  the  knee-chest,  or  knee-breast, 
position,  the  patient  kneels  in  bed,  and  then  bends  forward  until 
her  chest  comes  in  contact  with  the  bed  (v.  Fig.  192).  By  so  doing 
her  body  forms  an  inclined  plane — the  pelvic  end  being  the  highest, 
and,  in  consequence,  the  effect  of  gravity  is  to  cause  the  abdominal 
contents  to  drop  towards  the  diaphragm,  and  the  uterine  contents 
to  fall  towards  the  fundus.  The  position  is  of  use  in  obstetrical 
practice  for  two  purposes  : — first,  to  assist  efforts  at  the  reduction 
of  a  retroverted  pregnant  uterus,  and,  secondly,  to  diminish  as 
far  as  possible  the  force  with  which  the  presenting  part  presses 
against  the  pelvic  brim.  It  will  be  readily  understood  that,  in 
the  condition  known  as  prolapse  or  presentation  of  the  cord,  the 


336 


THE  PHYSIOLOGY  OF  LABOUR 


foetus  runs  a  considerable  risk  of  asphyxiation  in  consequence  of 
nipping  of  the  cord  between  the  presenting  part  and  the  pelvic 
brim,  and  that  anything  that  lessens  the  pressure  of  the 
presenting  part  against  the  brim  will  diminish  this  risk.  If  the 
patient  is  placed  in  the  knee-chest  position,  and  if  the  presenting 


The  Knee-Chest  Position. 


part  is  not  fixed,   the  latter  will  fall  away  from  the  brim  and 
pressure  upon  the  cord  will  temporarily  cease. 

Trendelenburg's  Position.  —  In  Trendelenburg's  position,  the 
patient  lies  on  her  back,  with  the  hips  considerably  raised  above 
the  level  of  the  remainder  of  the  body.  The  body  thus  forms 
an  inclined  plane,  as  in  the  knee-chest   position,   but  with   the 


Fig.   193. — An  Extemporised  Trendelenburg's  Position. 

difference  that  in  the  latter  position  the  back  of  the  patient  was 
uppermost,  while  in  Trendelenburg's  position  the  abdomen  is 
uppermost.  This  position  is  usually  adopted  in  operations  on 
the  pelvic  organs,  and  is  obtained  by  placing  the  patient  on  an 


WALCHER'S  POSITION 


337 


operating-table,  which  can  be  inclined  to  the  required  angle.  It 
may  also  be  used  as  a  substitute  for  the  knee-chest  position,  than 
which  it  is  more  comfortable,  in  cases  of  prolapse  of  the  cord.  As 
in  such  cases  the  patient  is  usually  in  bed,  an  extemporary  method 
of  maintaining  her  in  the  required  position  must  be  improvised. 
A  simple  method  of  doing  so  consists  in  laying  a  square  kitchen 
chair  on  its  face  along  the  bed,  the  top  back-rail  towards  the 
patient  (v.  Fig.  193).  The  back  of  this  is  then  well  padded  with 
cushions,  and  the  patient  placed  on  it  in  such  a  manner  that  her 
hips  are  the  highest  part  of  the  body. 

Walcher's  Position. — In  Walcher's  position,  the  patient  lies  on 
her  back  on  a  table  or  firm  bed  in  such  a  manner  that  the  sacrum 
rests  on  the  edge,  while  her  legs  hang  down  freely  without  support 


Fig.  194. — Walcher's  Position. 


(v.  Fig.  194).  The  position  is  named  after  Walcher,  who  originally 
drew  attention*  to  its  advantages  in  certain  cases.  It  results  in 
a  downward  rotation  of  the  pelvic  girdle  round  the  sacro-iliac 
joints  and  in  the  consequent  movement  of  the  symphysis  pubis 
away  from  the  promontory,  and  by  its  means  a  temporary  increase 
is  obtained  in  the  length  of  the  true  conjugate,  and  a  correspond- 
ing diminution  in  the  length  of  the  antero-posterior  diameter  of 
the  outlet.  According  to  Walcher,  this  increase  is  from  one-third 
to  half  an  inch  (0*85  to  13  cms.).  The  cause  of  the  rotation  of 
the  pelvic  girdle  is  to  be  found  in  the  weight  of  the  hanging 
limbs  which  weight  is  transmitted  to  the  innominate  bones 
through    the    Y-shaped    ligaments.     The  movement   is    akin   to 

*  'Die  Conjugata  eines  engen  Beckens  ist  Keine  Konstante  Grosse,'  etc., 
Centralb.  /.  Gyn.,  1889,  pp.  892,  893. 

22 


338 


THE  PHYSIOLOGY  OF  LABOUR 


that  described  by  Matthews  Duncan  under  the  term  '  nutation 
of  the  sacrum,'  and  only  differs  from  the  latter  in  that  in  sacral 
nutation  the  sacrum  is  said  to  alter  its  position  with  regard  to  the 
pelvic  girdle,  while  in  Walcher's  position  the  pelvic  girdle  alters 
its  position  with  regard  to  the  sacrum.  Walcher's  position  is  of 
considerable  value  in  all  cases  in  which,  in  consequence  of  a  slight 


I     / 


Fig.  195. — Diagram  showing  the  Effect  of  Walcher's  Position  on  the 
Length  of  the  True  Conjugate. 

10,  Length  of  C.V.  in  centimetres  when  the  patient  is  in  the  lithotomy 
position  ;  105,  length  when  in  Walcher's  position.     (Bumm.) 


disproportion  between  the  head  and  the  antero-posterior  diameters 
of  the  brim,  a  temporary  increase  in  the  length  of  the  latter  is 
required.  It,  however,  possesses  the  drawback  that  the  patient 
can  only  be  kept  in  it  for  a  short  time,  in  consequence  of  the 
extreme  discomfort  which  it  causes.  The  available  time  is,  how- 
ever, long  enough  to  permit  of  the  delivery  of  the  fore-coming 
head  with  forceps,  or  of  the  after-coming  head  with  the  fingers. 


THE  MANAGEMENT  OF  THE  FIRST  STAGE  339 

The  Management  of  the  First  Stage. — The  obstetrician's 
duties  during  the  first  stage  of  labour  are  not  many.  He 
must  first  determine  the  presentation  and  position  of  the  fcetus, 
the  state  of  the  genital  passages,  and  the  general  condition  of  the 
patient.  If  the  results  of  his  examination  show  that  the  case  is 
so  far  in  every  way  normal,  his  second  duty  is  to  facilitate  the 
phenomena  of  the  stage  so  far  as  possible. 

We  have  already  described  how  the  diagnosis  of  the  conditions 
of  labour  is  to  be  made.  The  obstetrician  should  first  obtain 
from  the  appearance  of  the  patient  as  much  information  as 
possible  regarding  her  condition,  general  health,  etc.  He  should 
count  the  pulse  and  note  its  strength,  and,  if  necessary,  take  the 
temperature  and  examine  the  heart  and  lungs.  He  should  then 
carefully  palpate  the  abdomen  of  the  patient,  and  next,  after 
thoroughly  disinfecting  his  hands,  he  should  make  a  vaginal 
examination.  Finally,  he  should  auscultate  the  foetal  heart,  in 
order  to  determine  the  condition  of  the  foetus. 

His  next  duty  consists  in  facilitating  the  normal  and  regular 
occurrence  of  the  phenomena  of  the  stage.  The  main  phenomena 
of  the  first  stage  are  the  taking  up  and  the  dilatation  of  the  cervix 
and  the  engagement  of  the  foetal  head  in  the  pelvic  brim,  if  this 
has  not  already  occurred.  Dilatation  of  the  cervix  can  be  facili- 
tated by  inducing  the  patient  to  walk  about,  or  to  sit  rather 
than  to  lie  down,  and  by  preserving  the  membranes  from  premature 
rupture.  The  uterine  contractions  of  the  first  stage  act  more 
advantageously  when  the  patient  is  in  an  erect  posture,  as  the 
action  of  gravity  increases  the  downward  pressure  of  the  ovum. 
In  this  matter,  patients,  as  a  rule,  require  little  urging,  as  they  are 
more  comfortable  whilst  walking  about  than  when  in  bed.  Pre- 
mature rupture  of  the  membranes  cannot  always  be  prevented, 
as  the  time  at  which  this  occurrence  takes  place  usually  depends 
on  the  adaptability  of  the  presenting  part  to  the  lower  uterine 
segment.  It  can,  however,  in  some  cases  be  warded  off  by  pre- 
venting '  bearing-down '  efforts  on  the  part  of  the  patient,  and  by 
keeping  her  in  bed  during  the  first  stage  in  all  cases  in  which  the 
membranes  protrude  unduly  into  the  vagina  during  a  contraction 
of  the  uterus.  It  is  unnecessary  to  remark  that  premature 
rupture  may  sometimes  be  the  result  of  a  maladroit  vaginal 
examination.  As  soon  as  the  uterine  orifice  is  completely  dilated 
the  membranes  are  no  longer  required,  and,  if  they  do  not  rupture 
spontaneously,  they  may  be  artificially  ruptured.  This  can  be 
done  by  cutting  them  through  by  means  of  a  scratching  move- 
ment of  the  finger-nail,  or  preferably  by  puncturing  them.  For 
the  latter  purpose,  the  sterilised  stilette  of  a  catheter  is  suitable, 
and  is  usually  at  hand. 

The  engagement  of  the  foetal  head  can  best  be  assisted  by 
seeing  that  the  axis  of  the  uterus  and  of  the  brim  as  nearly  as 
possible  coincide,  and  by  removing  any  obstacle  to  the  descent 
of  the  head.     As  a  rule,  the  axis  of  the  uterus  tends  to  fall  in 

22 — 2 


34o  THE  PHYSIOLOGY  OF  LABOUR 

front  of  the  axis  of  the  brim,  particularly  in  multiparae,  owing  to 
the  lax  condition  of  the  uterine  wall.  It  may  also  incline  to  one 
or  other  side.  The  best  means  of  correcting  any  such  deviation 
consists  in  pinning  a  binder  round  the  abdomen  in  such  a  manner 
as  to  lift  the  uterus  upwards,  and  to  press  it  in  the  required 
direction.  In  a  normal  case,  the  only  obstruction  which  may  be 
offered  to  the  descent  of  the  head  is  a  full  bladder  or  rectum, 
either  of  which  conditions  can  easily  be  removed. 

Abstention  from  unnecessary  interference  is  essential  through- 
out the  whole  of  labour.  In  the  first  stage,  the  amount  of  inter- 
ference which  is  necessary  in  a  normal  case  is  extremely  small. 
Once  the  obstetrician  has  made  his  diagnosis  of  the  nature  of 
the  case,  and  has  assured  himself  that  all  is  normal,  and  has 
given  the  necessary  directions  to  the  nurse  and  advice  to  the 
patient,  the  shorter  time  he  remains  in  the  patient's  room  the 
better  for  her.  There  is  nothing  so  bad  for  a  patient  as  a  fussy 
medical  attendant  or  nurse,  particularly  during  the  first  stage,  as 
her  sufferings  then  are  not  so  great  as  to  save  her  from  being 
worried  by  trifles.  Repeated  vaginal  examinations  are  not  only  un- 
necessary, but  harmful ;  the  preliminary  examination  over,  another 
should  not  be  made  until  the  commencement  of  the  second  stage, 
unless  the  first  stage  is  unduly  prolonged.  Once  the  obstetrician 
has  taken  over  the  management  of  the  case,  all  vaginal  examina- 
tion by  the  nurse  must  be  strictly  forbidden.  Fortunately,  in  the 
case  of  the  properly  trained  modern  nurse  such  a  precaution  is 
seldom  necessary,  as  she  will  herself  appreciate  the  necessity  for 
non-interference.  In  the  case  of  the  older  nurses,  who  considered 
that  it  was  part  of  their  duty  to  follow  the  entire  labour  with 
the  finger  in  the  vagina  and  to  assist  in  the  dilatation  of  the  os, 
the  difficulty  of  preventing  them  from  so  doing  was  considerable. 

Management  of  the  Second  Stage.  —  The  duties  of  the 
obstetrician  during  the  second  stage  are  more  important  and 
greater  in  extent,  although,  as  before,  they  fall  under  two  heads. 
He  has  to  determine  that  labour  is  proceeding  in  a  normal 
manner,  and  to  facilitate  the  phenomena  of  the  stage. 

To  determine  that  labour  is  proceeding  in  a  normal  manner, 
the  obstetrician  must  carefully  watch  the  appearance  of  the 
patient,  the  condition  of  her  pulse  and  temperature,  the  character 
of  the  uterine  contractions  and  their  effect  upon  the  uterus,  and 
the  mechanism  of  the  descent  of  the  head.  One  vaginal  ex- 
amination is  all  that  is  necessary  during  this  stage,  and  in  many 
cases  even  it  can  be  dispensed  with.  It  should  be  made  as  soon 
after  the  rupture  of  the  membranes  as  possible,  in  order  to 
determine  whether  a  foetal  limb  or  the  cord  has  prolapsed  during 
the  escape  of  the  liquor  amnii.  In  cases  in  which  the  first  vaginal 
examination  showed  that  the  head  was  fixed  in  the  pelvis  and 
filled  the  lower  uterine  segment,  this  second  examination  need 
not  be  made,  as  under  these  circumstances  it  is  impossible  that 


THE  MANAGEMENT  OF  THE  SECOND  STAGE  341 

any  prolapse  should  occur.  If  the  second  stage  is  unduly  pro- 
longed, it  will  probably  be  necessary  to  make  a  third  examination 
in  order  to  determine  the  cause  of  the  delay. 

The  principal  phenomenon  of  the  second  stage  is  the  expulsion 
of  the  foetus.  During  the  first  part  of  this  process— that  is,  until 
the  foetal  head  appears  at  the  vulva,  the  obstetrician  does  not 
need  to  give  any  active  assistance.  The  patient  is  kept  in  bed, 
as  in  this  position  she  can  best  assist  the  uterine  contractions 
by  voluntary  bearing-down  efforts.  These  efforts  are  now  en- 
couraged, and,  to  enable  her  to  make  them  with  greater  effect, 
a  towel  is  tied  to  the  foot  or  head  of  the  bedstead  in  such  a 
manner  that  she  can  take  it  in  her  hands  and  pull  upon  it  during 
a  bearing-down  effort.  If  an  occipito-posterior  position  of  the 
head  has  been  diagnosed,  we  may  encourage  forward  rotation  of 
the  occiput  by  pressing  up  the  forehead  with  the  fingers  in  the 
vagina  during  a  contraction,  and  so  increasing  flexion.  In  all 
cases,  the  patient  should  lie  on  the  side  to  which  the  occiput  is 
directed,  as  this  encourages  its  anterior  rotation. 

As  soon  as  the  foetal  head  appears  at  the  vulva,  the  assistance 
rendered  by  the  obstetrician  must  become  more  active,  and  he 
must  prepare  to  assist  the  birth  of  the  foetus  and  to  prevent 
the  laceration  of  the  perinaeum.  Numerous  methods  have  been 
recommended  for  preventing  laceration  of  the  perinaeum  ;  but 
some  of  these,  instead  of  being  of  value,  perhaps  actually  pre- 
dispose to  rupture.  In  whatever  method  is  adopted,  the  following 
objects  must  be  kept  in  view  : — 

( 1 )  The  Promotion  of  the  Relaxation  and  Dilatability  of  the  Parts. — 
We  have  seen  already  that  the  vagina  and  perinaeum  obtain 
their  power  of  extreme  dilatation  during  labour  mainly  from  a 
serous  infiltration  which  softens  and  relaxes  their  tissues.  We 
cannot,  perhaps,  very  materially  increase  the  amount  of  this 
transudation,  but  we  can  at  all  events  avoid  lessening  it.  All 
methods  which  aim  at  the  direct  support  of  the  perinaeum  have 
a  prejudicial  effect,  inasmuch  as  they  prevent  this  transudation 
by  squeezing  the  perinaeum  between  the  supporting  hand  and 
the  descending  head,  and  so  diminishing  the  blood-supply.  All 
astringent  antiseptics,  such  as  corrosive  sublimate,  have  a  some- 
what similar  effect,  and  in  addition  corrosive  sublimate  increases 
the  friction  between  the  presenting  part  and  the  mucous  mem- 
brane, and  so  increases  the  strain  on  the  perinaeal  tissues.  We 
can,  perhaps,  increase  the  dilatibility  of  the  perinaeum  to  a  slight 
extent  by  bathing  the  parts  constantly  with  hot  water  to  which 
an  antiseptic  such  as  lysol  has  been  added,  as  the  soap  in  the 
latter  acts  as  a  lubricant  and  diminishes  friction. 

(2)  Maintenance  of  Flexion  of  the  Head.  —  The  accompanying 
diagrams  (v.  Figs.  196,  197)  show  the  necessity  for  the  main- 
tenance of  flexion  until  the  lowest  possible  portion  of  the  occipital 
bone  lies  beneath  the  symphysis.  If  the  superior  portion  of 
the   occipital    bone    engages    beneath    the   symphysis,    then,    as 


342  THE  PHYSIOLOGY  OF  LABOUR 

the  head  rotates  round  this  point  during  extension,  a  diameter 
approximately    corresponding   with    the    occipito  -  frontal    must 


Fig.   196. — Diagram  showing  the  Manner  in  which  the  Head  ought 
not  to  pass  through  the  vulvar  orifice. 

The  longer  occipito-frontal  diameter  distends  the  perinaeum. 

distend  the  vaginal    orifice.     If,  on  the  other   hand,  a  point  on 
the  occipital  bone  below   the  occipital  prominence  fixes  behind 


Fig.  197. — Diagram  showing  the  Manner  in  which  the  Head  ought  to 
pass  through  the  Vulvar  Orifice. 

Flexion  is  maintained,  and  the  short  sub-occipito-frontal  diameter  distends  the 

perinaeum. 

the  symphysis,  the  sub-occipito-frontal  diameter  will  alone  have 
to  distend  the  vaginal  orifice — that  is  to  say,  a  diameter  of  four 


THE  MANAGEMENT  OF  THE  SECOND  STAGE  343 

inches  instead  of  one  of  four  and  a  half  inches.     The  method  of 
maintaining  flexion  will  be  described  presently. 

(3)  Delivery  between  the  Contractions. — If  the  head  is  expelled  by 
a  uterine  contraction  at  a  time  when  the  patient  is  straining  and 
bearing  down  forcibly,  the  danger  of  perinaeal  laceration  is  greatly 
increased,  as  is  the  difficulty  of  bringing  out  the  head  in  the  most 
suitable  position.  If,  on  the  other  hand,  we  can  prevent  the  head 
from  coming  out  during  a  contraction,  we  can  deliver  it  by  ex- 
pression from  behind  the  anus  assisted  by  the  voluntary  efforts  of 
the  woman  as  soon  as  the  contraction  is  over.  It  is  not,  however, 
always  possible  to  retard  expulsion,  but  we  can,  at  all  events, 
diminish  the  force  which  is  driving  the  head   downwards.     As 


Fig.  198. — The  Indirect  Method  of  Preserving  the  Perineum. 

The  heel  of  the  right  hand  pushes  the  head  forward  by  pressure  applied  be- 
tween the  anus  and  the  coccyx,  and  the  fingers  of  the  left  hand  endeavour 
to  draw  the  head  forward. 

soon  as  the  birth  of  the  head  appears  imminent,  take  away  the 
towel,  or  whatever  it  may  be,  upon  which  the  woman  is  pulling, 
and  as  soon  as  a  contraction  ensues,  desire  her  to  take  deep 
breaths  or  to  cry  out,  as  by  so  doing  she  prevents  herself  from 
bearing  down.  Then,  as  soon  as  the  contraction  has  passed  off, 
endeavour  to  express  the  head  in  the  manner  which  we  are  about 
to  describe,  and,  if  further  help  is  required,  desire  the  patient  to 
strain  down. 


344  THE.  PHYSIOLOGY  OF  LABOUR 

Accordingly — to  recapitulate,  a  method  of  preserving  the 
perinaeum  to  be  satisfactory  must  not  entail  direct  pressure  upon 
the  perinaeum,  must  maintain  flexion  of  the  head  as  long  as 
possible,  and  must  enable  us  to  deliver  the  head  between  the 
contractions. 

The  due  performance  ofthese  objects  will,  we  consider,  be  best 
ensured  by  the  following  method.  The  patient  lies  on  her  left  side, 
her  buttocks  projecting  beyond  the  edge  of  the  bed,  her  legs  drawn 
up,  and  separated  by  a  pillow.  The  obstetrician,  standing  by  the 
side  of  the  legs  at  the  level  of  the  buttocks,  passes  the  left  hand 
over  the  abdomen  of  the  patient,  and  brings  it  between  the  thighs 
from  before  backwards,  in  such  a  manner  that  the  advancing  head 
can  be  grasped  by  the  fingers  when  required  {v.  Fig.  343).  When 
a  contraction  occurs,  the  patient  is  told  to  cry  out  and  not  to  strain. 
If  by  this  means  the  force  of  the  contraction  is  so  weakened  that 
the  head  is  not  expelled,  so  much  the  better.  If,  however,  the 
contraction  is  strong  enough  to  drive  the  head  downwards,  all 
we  can  do  is  to  try  to  bring  the  latter  down  in  the  most  favourable 
position,  as  it  is  inadvisable  to  endeavour  to  hold  it  back.  With 
the  fingers  of  the  left  hand  applied  to  the  scalp,  endeavour  to 
draw  the  head  as  far  forwards  into  the  arch  of  the  pubis  as 
possible,  while  with  the  heel  of  the  right  hand  endeavour  to  press 
the  head  forwards,  and  at  the  same  time  to  keep  it  in  a  position  of 
flexion,  until  the  occipital  prominence,  or  a  point  below  it,  lies 
beneath  the  symphysis.  Further  pressure  with  the  fingers  of  the 
right  hand  will  then  result  in  producing  extension,  during  which 
the  head  will  be  born.  The  extent  to  which  the  head  can  be 
drawn  forwards  by  means  of  the  fingers  of  the  left  hand  is  of 
course  very  slight,  until  a  sufficient  part  of  the  head  has  been 
born  to  afford  a  firm  grip.  The  forward  pressure  of  the  right 
hand  is  applied,  not  on  the  perinaeal  body,  but  over  the  area 
bounded  anteriorly  by  the  anus,  laterally  by  the  tubera  ischii, 
and  posteriorly  by  the  tip  of  the  coccyx.  When  the  head  is 
distending  the  perinaeum,  its  outline  can  readily  be  felt,  and  with 
a  little  practice  we  know  exactly  what  part  of  the  head  we  are 
pressing  upon. 

If  we  are  able  so  to  lessen  the  strength  of  the  contraction  that 
it  does  not  expel  the  head,  as  soon  as  it  is  over  we  apply  pressure 
behind  the  anus,  as  has  been  described.  For  such  pressure  to  be 
effective  the  head  must  be  sufficiently  low  down,  otherwise  our 
pressure  will  merely  drive  it  back  into  the  uterus.  If  we  find,  on 
applying  pressure,  that  the  head  is  not  sufficiently  low,  we  must 
wait  until  another  contraction  has  occurred,  and  then  try  again. 
If  the  head  is  sufficiently  low,  but  the  resistance  to  its  birth  is  too 
great  to  allow  it  to  be  expressed  in  this  manner,  the  patient  must 
be  made  to  bear  down  slightly,  and  then,  as  a  rule,  the  head  can 
be  delivered. 

The  direct  method  of  supporting  the  perinaeum  differs  essentially 
from  the  foregoing.     The  palm  of  the  right  hand  is  laid  over  the 


PRESERVATION  OF  THE  PERIN.EUM  345 

perinaeum  in  such  a  manner  that  the  concavity  between  the  thumb 
and  index  finger  corresponds  to  the  posterior  margin  of  the  vaginal 
orifice.  As  the  head  distends  the  perineum,  the  latter  is  sup- 
ported and  prevented  from  becoming  overdistended,  while,  at  the 
same  time,  the  head  is  gently  pressed  in  the  direction  of  the 
symphysis.  The  objection  to  any  such  method  is — as  has  been 
mentioned — that  the  natural  mechanism  by  which  the  perinaeum 
is  rendered  dilatable  is  hindered.  Furthermore,  the  method  is  not 
of  much  practical  value.  We  can  prevent  by  pressure  the  peri- 
naeum from  bulging  downward  any  farther  than  we  think  fit,  but 
we  cannot  prevent  it  from  splitting  down  the  middle  in  order  to 
allow  room  for  the  advancing  head,  and  this  is  in  all  probability 
what  occurs  when  the  perinaeum  is  directly  supported.  Indeed, 
it  is  not  improbable  that  rupture  occurs  in  a  greater  percentage  of 
cases  than  would  be  the  case  if  the  expulsion  of  the  head  was  left 
to  Nature.  It  is  not  difficult  to  understand  why  this  should  be  so. 
Direct  pressure  upon  the  perinaeum  cannot  increase  its  dilata- 
bility,  nor  can  it  diminish  the  diameters  of  the  head,  which  must 
distend  it.  If  the  perinaeal  dilatability  is  not  sufficient  to  allow 
room  for  the  head  to  pass,  the  perinaeum  will  rupture  whether  we 
support  it  or  not.  Consequently,  there  is  no  appreciable  gain 
obtained  from  mere  support.  If,  on  the  other  hand,  we  support 
it  too  strongly,  we  perhaps  prevent  it  from  bulging  downwards  to 
that  degree  to  which,  if  uninterfered  with,  it  would  have  bulged 
without  rupture,  and  in  such  cases  the  perinaeum  is  compelled  to 
rupture  in  order  to  allow  the  head  to  pass,  even  though  its 
maximum  amount  of  distension  has  not  been  reached.  In  short, 
the  direct  method  has  nothing  to  recommend  it,  and  should  not  be 
adopted. 

Several  methods  have  been  recommended,  in  the  performance 
of  which  the  fingers  are  introduced  into  the  rectum.  The 
'  manoeuvre  of  Ritgen  '*  consists  in  passing  the  index  and  middle 
fingers  into  the  rectum  and  making  pressure  upon  the  forehead  of 
the  foetus,  while  at  the  same  time  the  thumb  close  to  the  four- 
chette  controls  the  part  of  the  head  that  is  already  born.  It  is 
obvious  that  by  this  means  we  are  applying  a  pressure  to  the 
head  which  can  be  just  as  well  applied  externally  over  the 
ano-coccygeal  space,  as  we  have  described,  and  this,  too,  without 
soiling  the  fingers.  Goodellf  recommended  hooking  two  fingers 
into  the  rectum  and  drawing  it  forward,  with  the  object  of 
lengthening  the  perinaeum,  while  at  the  same  time  the  thumb 
controls  the  advance  of  the  head  All  methods  in  which  the 
fingers  are  introduced  into  the  rectum  are  objectionable,  while 
Goodell's  method  in  particular  probably  tends  to  cause  laceration 
of  the  rectal  mucous  membrane. 

*  '  Ueber  ein  Dammschutzverfahren,'  Monatss.  f.  Geburts.,-  1855,  vi. 
321-347- 

f  '  A  Critical  Inquiry  into  the  Management  of  the  Perinaeum  during 
Labour,'  Amci:  Jouni.  of  Med.  Sciences,  1871,  vol.  lxi. ,  pp.  53-79. 


346  THE  PHYSIOLOGY  OF  LABOUR 

In  some  cases  in  which,  owing  to  the  small  size  of  the  vaginal 
orifice,  serious  laceration  appears  to  be  certain  to  occur,  it  is 
advisable  to  perform  the  operation  known  as  episiotomy — that  is, 
to  incise  the  perinaeum  in  such  a  manner  as  to  increase  the  size  of 
the  vaginal  orifice.  This  procedure  was  first  recommended  by 
Fielding  Ould*  in  1742,  and  since  then  has  had  intervals  of 
popularity  and  unpopularity.  There  is  no  doubt  that  the  clean- 
cut  incision  made  by  scissors  will  in  some  cases  be  smaller,  and 
will  heal  more  readily  than  the  large  laceration  which  might 
otherwise  result,  and,  further,  that  such  an  incision  may  save  the 
involvement  of  the  rectal  wall  or  sphincter  ani.  It  is,  however, 
difficult  to  foretell  before  a  laceration  occurs  its  probable  course 
and  extent,  and,  consequently,  it  is  difficult  to  know  what  cases 
are  suitable  for  episiotomy  and  what  cases  are  not.  It  is,  how- 
ever, always  well  to  have  a  stout  pair  of  blunt-pointed  scissors  at 
hand,  and  if  the  degree  of  dilatation  of  the  perinaeum  is  excessive 
before  the  large  diameters  of  the  head  distend  it,  episiotomy  may 
be  performed.  The  method  of  doing  so  will  be  subsequently 
described. 

We  wish  to  impress  on  our  readers  the  necessity  of  having  an 
uninterrupted  view  of  the  expulsion  of  the  foetus  and  the  dilatation 
of  the  perinaeum.  It  ought  not  to  be  necessary  to  do  so  at  the 
present  day,  but,  in  view  of  the  fact  that  some  text-books  appear 
to  imply  that  it  is  not  always  necessary  to  have  such  a  view,  we 
think  it  well  to  insist  upon  the  point.  Presumably,  when  non- 
exposure  of  the  parts  is  adopted,  it  is  done  with  the  object  of 
sparing  the  feelings  of  the  patient,  but,  during  the  expulsion  of 
the  foetus,  the  patient  is  far  too  much  occupied  by  her  sufferings 
to  notice  what  is  done,  and,  moreover,  no  sensible  patient  will 
object  to  a  precaution  taken  for  her  own  good,  if  the  necessity  for 
it  is  made  clear  to  her.  The  patient's  sensibilities  have  in  the  past 
been  too  frequently  considered  to  the  detriment  of  her  physical 
condition.  Catheters  have  been  passed  by  touch,  and  cystitis  set 
up.  Vaginal  examinations  have  been  made  under  the  clothes — the 
fingers  being  guided  into  the  vagina  by  passing  them  up  the  back 
of  the  thighs  to  the  buttock,  and  then  over  the  perinaeum  and 
fourchette  tothe  entrance  of  the  vagina,  and  septic  infection  has 
resulted.  The  foetus  has  been  delivered  under  the  bedclothes, 
and  the  perinaeum  torn  into  the  rectum  without  the  medical 
attendant  being  any  the  wiser.  Such  practices  are  now,  we  hope, 
abandoned  for  ever.  At  one  time  they  were  the  sign  of  the  skilful 
obstetrician  ;  they  are  now  the  sign  of  the  ignorant  one. 

As  soon  as  the  head  has  been  delivered,  the  next  duty  of  the 
obstetrician  is  to  ascertain  that  the  cord  is  not  twisted  round  the 
neck.  To  do  this,  he  slips  one  or  two  fingers  into  the  vagina 
until  the  neck  is  reached,  and  feels  carefully  in  all  directions.  If 
the  cord  is  round  the  neck,  it  must  be  set  free  in  some  manner,  as 
otherwise  it  may  be  so  short  as  to  prevent  the  birth  of  the  foetus. 

*  '  A  Treatise  on  Midwifery,'  p.  145. 


DELIVERY  OF  THE  TRUNK  347 

The  usual  method  of  doing  this  consists  in  drawing  down  a  loop 
and  slipping  it  over  the  head.  If  there  is  a  second  loop,  it  must  be 
drawn  down  in  a  similar  manner.  In  some  cases,  the  cord  may  be 
so  tightly  round  the  neck  that  it  is  impossible  to  draw  it  down, 
and,  as  immediate  delivery  of  the  foetus  is  necessary,  some  other 
method  of  freeing  it  must  be  adopted.  Accordingly,  in  such  cases 
make  the  patient  bear  down,  or  apply  pressure  over  the  fundus  of 
the  uterus,  and  as  the  foetus  descends  slip  the  cord  first  over  one 
shoulder  and  then  over  the  other.  The  result  of  this  is  that  the 
foetus  descends  through  the  loop  in  the  cord.  If  the  portion  of 
cord  round  the  neck  is  so  short  as  to  prevent  even  this  manoeuvre, 
the  loop  must  be  divided  with  scissors,  and  the  foetus  quickly 
delivered  by  pressure  upon  the  fundus  and  traction  on  the  head. 
The  foetal  end  of  the  cord  is  then  immediately  ligated.  It  is  quite 
unnecessary  to  ligate  the  cord  before  it  is  divided,  as  the  com- 
pression to  which  it  is  subjected  during  the  expulsion  of  the  foetus 
will  prevent  any  haemorrhage  from  occurring. 

If  the  cord  is  not  round  the  neck,  or,  if  being  so  at  first,  it  is 
set  free  and  is  found  to  be  pulsating,  it  is  not  necessary  to  unduly 
hurry  the  expulsion  of  the  trunk.  Usually,  in  half  a  minute  or  so 
after  the  birth  of  the  head,  a  uterine  contraction  occurs  and  drives 
the  shoulders  down.  As  they  descend,  lift  the  head  forwards 
between  the  thighs  in  the  direction  of  the  mother's  abdomen,  in 
order  to  bring  the  posterior  shoulder  over  the  perinaeum.  Then 
draw  the  head  slightly  backwards,  in  order  to  bring  the  anterior 
shoulder  from  behind  the  symphysis.  In  this  way  both  shoulders 
are  delivered,  and  by  again  drawing  the  head  and  shoulders 
forward  the  rest  of  the  body  follows.  The  left  hand  on  the  fundus 
should  follow  down  the  descending  uterus,  and  note  that  it 
is  contracting  properly.  If  it  is  necessary  to  expedite  the  ex- 
pulsion of  the  shoulders  for  any  reason,  always  endeavour  to  do 
so  first  by  pressure  over  the  fundus,  and  if  this  fails  then  apply 
traction  to  the  head.  Pressure  applied  over  the  fundus  has  the 
same  effect  as  have  the  contractions  of  the  uterus,  and  does  not 
in  any  way  interfere  with  the  ordinary  mechanism  of  delivery. 
Traction  applied  to  the  head  before  internal  rotation  of  the 
shoulders  has  occurred  may,  on  the  other  hand,  interfere  with 
the  ordinary  mechanism,  and  lead  to  the  impaction  of  the 
shoulders  in  the  pelvis.  If  we  are  finally  obliged  to  pull  upon 
the  head,  we  must  at  the  same  time  rotate  it  gently  in  whatever 
direction  rotation  of  the  shoulders  is  occurring.  It  is  advisable 
to  pass  the  fingers  into  the  vagina  along  the  child's  body  to 
ascertain  the  position  of  the  shoulders,  and  if  either  axilla  has 
descended  sufficientlv  low  to  be  within  reach,  to  hook  a  finger 
into  it  and  apply  traction.  Even  a  normal  case  may  sometimes 
require  such  assistance,  but,  if  a  case  cannot  be  delivered  by  this 
means,  it  shows  that  it  has  ceased  to  be  normal,  and  that  the 
shoulders  have  become  impacted.  The  treatment  of  such  a  con- 
dition will  be  referred  to  in  its  proper  place. 


348  THE  PHYSIOLOGY  OF  LABOUR 

There  is  a  question  of  practical  importance  which  will  occur  to 
many  regarding  the  management  of  the  second  stage,  and  that  is, 
Is  it  necessary  to  adopt  any  special  measures  in  the  case  of 
occipito-posterior  positions  of  the  vertex  ?  As  we  have  seen,  in 
the  large  proportion  of  cases  the  occiput  rotates  anteriorly,  while 
in  others  it  rotates  posteriorly  and  causes  a  corresponding  delay 
in  labour.  In  the  first  class  of  case  any  interference  is  un- 
necessary, but  in  cases  in  which  posterior  rotation  is  probable  it 
is  obvious  that  everything  should  be  done  to  promote  anterior 
rotation.  Such  an  answer  is  not,  however,  of  any  practical  value, 
as  we  cannot  tell  beforehand  whether  in  a  given  case  the  occiput 
will  rotate  anteriorly  or  posteriorly.  Before  answering  the  question 
definitely,  let  us  first  see  what  are  the  various  ways  by  which  the 
position  can  be  corrected.  This  can  be  done  by  one  or  other  of  the 
following  methods,  according  to  the  circumstances  of  the  case : — 

Rotation  of  the  Foetus  by  External  Manipulations. — This  method 
is  described  by  Herman.*  It  can  be  performed  in  all  cases  in 
which  the  membranes  are  unruptured  and  the  head  above  the 
pelvic  brim,  and  consists  in  rotating  the  body  of  the  foetus  on  its 
long  axis  by  means  of  gentle  pushing  movements  as  in  external 
version.  The  movements  are  made  in  such  a  direction  that  the 
anterior  shoulder  moves  towards  the  opposite  side  of  the  pelvis 
to  that  at  which  it  previously  lay,  and  the  back  comes  to  lie 
anteriorly.  Thus,  if  the  foetus  originally  lay  in  a  first  position 
with  the  back  posteriorly,  and  its  anterior  shoulder  at  the  anterior 
end  of  the  right  oblique  diameter,  this  shoulder  is  pushed  to  the 
right  until  it  lies  at  the  anterior  end  of  the  left  oblique  diameter. 
The  fcetus  then  lies  in  the  first  position  with  the  back  in  front. 
The  head  should  be  held  over  the  brim  in  this  position  until  it 
becomes  fixed,  or,  if  the  os  is  fully  dilated,  the  membranes  may 
be  ruptured  and  a  tight  abdominal  binder  applied.  In  this  way, 
the  same  end  will  be  obtained. 

The  Production  of  Increased  Flexion. — As  we  know,  one  of  the 
most  important  causes  of  posterior  rotation  of  the  occiput  is  in- 
sufficient flexion,  and  consequently  a  very  proper  way  of  preventing 
the  occurrence  of  posterior  rotation  is  by  increasing  flexion.  This 
can  be  done — at  all  events  to  a  slight  extent — at  almost  any  stage 
of  labour  by  passing  two  fingers  into  the  vagina,  and  firmly,  but 
without  violence,  pushing  up  the  forehead  during  a  uterine  con- 
traction. This  procedure  is  repeated  during  several  contractions, 
and  as  no  increased  resistance  is  offered  to  the  descent  of  the 
occiput,  the  latter  descends,  and  the  degree  of  flexion  is  increased. 
Flexion  can  also  be  produced  by  pulling  down  the  occiput  instead 
of  by  pushing  up  the  forehead.  This  procedure,  however,  neces- 
sitates the  use  of  an  instrument  known  as  a  vectis,  which  is 
not,  as  a  rule,  to  be  found  in  the  armamentarium  of  the  modern 
obstetrician.  It  has  nothing  particular  to  recommend  it,  and, 
consequently,  need  not  be  described. 

*   '  Difficult  Labour,'  second  edition,  p.  9. 


THE  MANAGEMENT  OF  OCCIPITO-POSTERIOR  POSITIONS     349 

Rotation  of  the  Head  by  Internal  Manipulation. — This  method 
is  adopted  by  Tarnieiy"  by  whom  it  was  described,  and  is  carried 
out  as  follows  : — Pass  into  the  vagina  the  index  finger  of  whatever 
hand  corresponds  to  the  side  towards  which  the  anterior  ear  of  the 
foetus  is  directed.  If  the  foetus  lies  in  the  first  position  with  the 
back  behind,  the  right  ear  will  be  anterior  and  point  towards 
the  left  side,  consequently  the  right  finger  will  be  used.  Pass 
this  finger  upwards  beside  the  head  until  it  lies  behind  the  right 
ear,  and  then,  keeping  it  fixed  in  this  position,  wait  for  a  con- 
traction and,  as  soon  as  this  occurs,  carry  it  steadily  and  firmly 
forwards  along  the  back  of  the  left  pubic  bone  and  past  the 
symphysis  until  it  reaches  a  corresponding  position  at  the  opposite 
side.  In  this  way  the  head  is  rotated  until  the  right  ear,  which 
originally  lay  at  the  anterior  end  of  the  right  oblique  diameter,  has 
come  to  lie  at  the  anterior  end  of  the  left  oblique  diameter.  This 
manipulation  is  best  performed  at  the  end  of  the  first  stage  or  at 
the  commencement  of  the  second,  and  the  attempt  at  rotation  is 
made  just  as  a  contraction  is  about  to  occur.  If  the  necessary 
amount  of  rotation  has  not  been  obtained  by  the  time  the  contrac- 
tion has  ended,  wait  for  the  next  contraction,  keeping  the  head 
in  the  position  it  has  reached  by  a  slight  pressure  of  the  fingers, 
and  then  repeat  the  attempt.  Internal  rotation  can  also  be  pro- 
duced by  means  of  the  forceps.  This  procedure  was  first  described 
by  Smellie,t  to  whom  it  gave  '  great  joy.'  It  is  not,  however,  a 
practice  which  can  be  recommended,  as  it  may  lead  to  injuries  of 
the  head  of  the  foetus  and  of  the  maternal  soft  parts. 

Rotation  by  Combined  External  and  Internal  Manipulation. — 
This  method  consists  in  passing  one  hand  into  the  vagina  and 
grasping  the  head  internally  with  it,  while  the  other  hand,  on  the 
abdominal  wall,  lies  over  the  anterior  shoulder.  Then,  by  internal 
rotation  of  the  head  assisted  by  pressure  upon  the  anterior  shoulder 
in  the  required  direction,  the  occiput  is  brought  anterior.  If  the 
shoulders  follow  the  rotation  of  the  head  to  the  required  extent, 
the  head  will  remain  in  its  new  position  ;  if  the  shoulders  have 
not  rotated,  the  head  will  slip  back  again  into  its  former  position. 

We  must  now  answer  the  question  which  we  have  asked.  Is 
it  necessary  to  correct  every  occipito-posterior  position  of  the  head 
by  one  of  the  foregoing  methods  ?  Most  authorities  will  disagree 
in  the  answer.  We  consider  that  if  the  head  is  not  fixed,  and  if 
the  foetus  can  be  rotated  by  external  manipulation,  it  is  well  to  do 
so.  If  external  manipulation  fail  we  may,  perhaps,  endeavour  to 
cause  rotation  by  promoting  flexion  in  the  manner  that  has  been 
described  and  by  directing  the  patient  to  lie  on  the  side  to  which 
the  occiput  is  turned.  Otherwise,  the  case  may  be  left  to  Nature. 
Even  if  the  occiput  does  rotate  posteriorly,  eventually,  in  most 
cases,  labour  will  end  naturally.     If  it  is  delayed,  extraction  with 

*  Ribemont-Dessaignes  and  Lepage,  p.  398. 

t  'Theory  and  Practice  of  Midwifery,'  New  Sydenham  Society's  edition, 
vol.  ii.,  p.  339. 


350  THE  PHYSIOLOGY  OF  LABOUR 

the  forceps  is  not  difficult.  Herman  states,  that,  in  cases  in  which 
prolonged  traction  had  been  made  with  the  forceps  without 
success,  he  has  frequently  succeeded  in  rotating  the  occiput  for- 
wards by  combined  external  and  internal  manipulation,  and  has 
then  easily  effected  delivery  by  the  forceps.*  Accordingly,  in 
such  cases,  this  procedure  may  be  tried. 

The  Management  of  the  Third  Stage. — In  a  case  of 
normal  labour,  the  third  stage  is  the  one  which  requires  the 
most  careful  attention  on  the  part  of  the  obstetrician.  As  we 
have  already  seen,  the  contractions  of  the  uterus  can,  unaided, 
effect  the  expulsion  of  the  foetus,  the  detachment  of  the  placenta, 
and  the  expulsion  of  the  latter  from  the  uterus ;  but  they,  as  a 
rule,  fail  to  bring  about  the  expulsion  of  the  placenta  from  the 
vagina  within  a  reasonable  time,  owing,  in  all  probability,  to  the 
artificial  surroundings  and  position  of  the  patient.  Consequently, 
skilled  aid  is  required  to  assist  in  the  delivery  of  the  after-birth. 
Further,  the  liability  to  haemorrhage,  as  a  result  of  the  detach- 
ment of  the  after-birth,  appears  to  be  considerable  amongst 
civilized  races,  and  on  this  account  also  skilled  assistance  is  very 
necessary  during  the  third  stage. 

The  duties  of  the  obstetrician  during  the  third  stage  consist  in 
facilitating  the  detachment  and  expulsion  of  the  placenta,  and  in 
preventing  the  occurrence  of  haemorrhage.  Clinically,  we  divide 
the  third  stage  into  two  periods,  in  correspondence  with  the  two 
stages  in  the  expulsion  of  the  after-birth.  During  the  first  period, 
the  placenta  is  detached  and  expelled  from  the  cavity  of  the  uterus 
into  the  lower  uterine  segment  or  the  vagina.  During  the  second 
period  the  placenta  is  expelled  from  the  lower  uterine  segment 
or  vagina  externally.  During  the  first  period,  the  duties  of  the 
obstetrician  are  to  promote  the  contraction  and  retraction  of  the 
uterine  fibre  in  order  to  bring  about  the  detachment  and  expulsion 
of  the  placenta.  During  the  second  period,  his  duty  is  to  still 
promote  contraction  and  retraction,  and,  in  addition,  to  expel  the 
placenta  from  the  vagina. 

As  soon  as  the  infant  is  born,  the  patient  is  turned  from  the 
lateral  position  on  to  her  back,  and  the  medical  attendant  places 
his  hand  upon  the  fundus  of  the  uterus.  He  maintains  the  hand 
in  this  position  during  the  entire  stage,  in  order  to  note  the  occur- 
rence of  contraction  and  relaxation  of  the  uterus,  to  promote 
contraction  by  gentle  friction  of  the  fundus,  and  to  prevent  the 
accumulation  of  clots  in  the  cavity  in  cases  in  which  the  con- 
tractions are  feeble  or  absent.  He  further  notes  by  this  means 
the  rising  of  the  uterus  into  the  abdomen,  an  occurrence  which 
shows  that  the  placenta  has  been  expelled.  The  hand  must  be 
so  applied  to  the  uterus  that  it  covers  the  fundus  completely — 
roofing  it  over  as  it  were.  If  the  hand  is  applied  to  the  anterior 
surface  of  the  uterus,  the  fundus  may  slip  away  above  it,  and 

*  Op.  tit.,  p.  13. 


THE  MANAGEMENT  OF  THE  THIRD  STAGE  351 

then  the  stimulation  of  the  hand  may  cause  the  lower  uterine 
segment  to  contract  while  the  fundus  remains  in  a  more  or  less 
relaxed  condition  above.  In  this  manner,  irregular  contractions 
of  the  uterus  are  set  up,  and  these  may  result  in  the  incarceration 
of  the  placenta  or  in  the  occurrence  of  post-partum  haemorrhage 
due  to  the  accumulation  of  clots  in  the  uterine  cavity.  Perhaps 
the  best  method  of  applying  the  hand  consists  in  sinking  its  ulnar 
edge  transversely  into  the  abdomen  just  below  the  umbilicus, 
until  it  meets  the  resistance  offered  by  the  spinal  column.  The 
entire  uterus  is  then  below  the  palm  of  the  hand. 

The  object  of  placing  the  patient  in  the  dorsal  position  is 
obvious.  In  the  first  place,  the  obstetrician  can,  with  far  greater 
ease,  '  control '  the  uterus,  and,  in  the  second  place,  the  uterus 
tends  to  sink  into  the  pelvis  and  so  to  occlude  the  dilated  vagina. 
When,  however,  the  patient  is  in  the  lateral  position,  the  uterus 
tends  to  fall  to  one  or  other  side  and  to  draw  the  vagina  upwards 
with  it.  Such  a  movement  may  cause  a  negative  pressure  inside 
the  vagina  and  so  facilitate  the  entrance  of  air. 

We  must  now  consider  the  management  of  the  placenta.  As  we 
have  seen,  the  contractions  of  the  uterus  will  suffice  to  detach  the 
placenta  and  to  expel  it  into  the  vagina,  and  this  will,  as  a  rule, 
take  place  within  a  comparatively  short  period  after  the  delivery 
of  the  foetus.  The  further  expulsion  of  the  placenta  is,  however,  a 
tedious  process,  and  may  take  a  considerable  number  of  hours  if 
left  to  the  natural  efforts  alone.  Moreover,  the  detachment  and 
expulsion  of  the  placenta  from  the  uterus  is  a  process  which  can 
really  be  only  satisfactorily  carried  out  by  the  natural  mechanism. 
It  must  be  remembered  that  not  only  has  the  placenta  to  be 
detached,  but  the  mouths  of  large  uterine  bloodvessels  have  to 
be  permanently  closed  in  order  that  haemorrhage  from  them  may 
not  occur.  The  closure  of  these  vessels  is  mainly  brought  about 
by  uterine  retraction,  and  this  process  requires  a  little  time  and 
several  contractions  of  the  uterus  to  complete.  If  the  placenta 
is  detached  by  the  forcible  compression  of  the  uterine  walls  from 
without,  retraction  may  not  at  the  time  be  complete,  and  haemor- 
rhage will  result.  If,  on  the  contrary,  its  detachment  is  left  to  the 
natural  efforts,  we  can  be  sure  that,  by  the  time  it  is  completely 
detached,  retraction  will  be  complete.  Further,  it  is  all-important 
that  the  entire  placenta  should  come  away  and  that  no  fragments 
should  be  left  adherent  to  the  uterus.  Unless  the  adhesions 
between  the  placenta  and  the  uterus  are  pathologically  dense, 
a  normal  amount  of  contraction  and  retraction  will  serve  to  com- 
pletely break  them  down.  If,  however,  we  endeavour  to  break 
them  down  by  forcible  compression  of  the  uterus  from  without,  it 
is  extremely  probable  that  fragments  of  the  placenta  will  be  torn 
off  and  left  in  the  uterus.  The  expulsion  of  the  placenta  from 
the  vagina  is  quite  another  matter.  There  are  no  adhesions 
holding  it  in  this  position,  and  all  that  is  needed  to  procure 
its  expulsion  is  a  sufficient  expelling  force.     This  force  can  be 


352  THE  PHYSIOLOGY  OF  LABOUR 

safely  supplied  by  the  obstetrician,  and  inasmuch  as  the  natural 
mechanism  by  which  the  second  stage  of  placental  delivery  is 
effected  is  a  slow  and  tedious  one,  it  is  proper  that  in  all  cases 
the  obstetrician  should  supply  it.  Accordingly,  we  see  that,  while 
the  first  period  of  the  third  stage  should  be  left  altogether  to  the 
natural  efforts,  in  the  second  period  the  obstetrician  may  come  to 
the  assistance  of  Nature  and  complete  the  delivery  of  the  placenta. 

It  may,  however,  be  that,  even  in  the  first  period,  the  natural 
efforts  are  not  sufficient  to  effect  the  detachment  of  the  placenta 
and  its  expulsion  from  the  uterus,  either  owing  to  insufficient 
contractions  of  the  uterus,  to  too  dense  adhesions  between  the 
placenta  and  the  uterus,  or  to  other  cause.  What  is  to  be  done 
in  such  cases  ?  We  cannot  allow  the  third  stage  to  last  for  an 
unduly  long  period  ;  but  when  should  we  interfere  ?  This  question 
can  be  best  answered  in  Crede's  words : — '  The  uterus  should 
expel  the  after-birth,  and  the  sooner  it  does  so  after  the  expulsion 
of  the  foetus  the  better.  If  it  does  not  do  so  it  must  be  made  to 
do  so,  otherwise  it  may  be  too  late  and  the  dangers  of  retained 
placenta  come  into  force.'  To  act  in  accordance  with  this  dictate 
we  must  give  the  uterus  a  reasonable  time  in  which  to  expel  the 
placenta,  and  if  it  does  not  do  so  within  this  time  we  must  help  it 
to  do  so.  In  practice,  we  shall  find  that  the  uterus,  as  a  rule, 
expels  the  placenta  into  the  vagina  within  ten  minutes  of  the 
birth  of  the  infant,  but  that  sometimes  it  may  not  have  done  so 
at  the  end  of  an  hour.  If  it  has  not  done  so  by  that  time  there 
is  little  to  be  gained  by  waiting  any  longer,  and  steps  must  be 
taken  to  effect  delivery. 

There  are  three  principal  methods  by  which  the  delivery  of  the 
placenta,  either  from  the  uterus  or  the  vagina,  can  be  effected  : — 
(i)  Expression  from  above. 

(2)  Manual  removal. 

(3)  Traction  upon  the  cord. 

Expression. — The  expression  of  the  placenta  by  pressure  on  the 
fundus  through  the  abdominal  wall  is  the  most  satisfactory  method 
of  expelling  the  placenta  in  most  cases  in  which  it  is  retained  in 
the  uterus,  and  in  all  cases  in  which  it  is  lying  in  the  vagina.  To 
perform  it,  we  grasp  the  fundus  through  the  abdominal  wall,  with 
one  or  both  hands,  during  a  contraction  (v.  Fig.  199).  If  we  are 
compelled  to  express  the  placenta  from  the  uterus,  we  compress 
the  body  of  the  uterus  from  above  downwards,  and  from  side  to 
side,  in  such  a  manner  as  to  squeeze  out  its  contents  into  the 
vagina.  Then,  we  press  the  uterus  downwards  and  backwards 
in  the  direction  of  the  last  piece  of  the  sacrum.  By  this  means, 
the  uterus  is  pressed  downwards  into  the  vagina  and  the  placenta 
is  driven  out  before  it.  If  the  placenta  is  already  in  the  vagina, 
we  omit  the  initial  compression  of  the  uterus. 

The  importance  of  this  method  of  effecting  the  delivery  of  the 
placenta  can  hardly  be  overestimated,  inasmuch  as  it  enables  us 
to  entirely  dispense  in  almost  every  case  with  internal  manipula- 


THE  MANAGEMENT  OF  THE  THIRD  STAGE  353 

tions,  and  thus  to  follow  an  important  principle  of  modern 
obstetrics,  which  we  have  already  enunciated — i.e.,  the  substitu- 
tion, whenever  possible,  of  external  for  internal  manipulations. 
The  origin  of  the  method  is  therefore  of  interest.  By  some 
writers  it  is  termed  the  '  Dublin  method,'  whilst  by  others,  and 
they  constitute  the  majority,  it  is  termed  Crede's  method.  We 
cannot  here  enter  into  the  various  reasons  which  make  us  con- 
sider that  the  former  term  is  the  more  correct.  It  is  sufficient  to 
quote  the  words  of  Barnes  ::::  '  This  plan  of  causing  the  uterus  to 


Fig.   199. — Expression  of  the  Placenta  by  the  Dublin  Method. 
U,  The  uterus  ;  PI,  the  placenta. 

contract  and  expel  the  placenta  by  manual  compression  has, 
within  the  last  few  years,  been  introduced  into  Germany  as  a 
discovery  by  Dr.  Crede,  without  a  suspicion  apparently  that  it 
had  long  been  a  familiar  practice  in  this  country.'  It  is  insisted 
on  with  detail  by  Hardy  and  M'Clintock,f  while  M'Clintock,  in 
his  introduction  to  Smellie's  '  Midwifery,'!  alludes  to  the  method 
as  having  '  been  practised  from  time  immemorial  at  the  Dublin 
Lying-in  Hospital.'     The  method  first  originated  in  Dublin,  and 

*  '  Obstetrical  Operations,'  third  edition,  p.  522. 
t  '  Practical  Observations  on  Midwifery,'  p.  221. 
I  Op.  cit.,  vol.  i.,  p.  236. 

23 


354  THE  PHYSIOLOGY  OF  LABOUR 

the  undoubted  fact  that  Crede  *  discovered  it  for  himself  de  novo, 
and  did  much  to  teach  the  medical  profession  its  value,  is  no 
reason  that  its  correct  title  should  be  abandoned.  \ 

Manual  Removal. — The  placenta  can  be  easily  detached  and 
removed  from  the  uterus  or  vagina  with  the  hand  introduced 
into  the  genital  passages.  The  objections  to  such  a  course  of 
procedure  in  normal  cases  are,  however,  many  and  obvious.  In 
the  first  place,  such  a  procedure  is  directly  opposed  to  the  principle 
of  modern  obstetrics  to  which  we  have  already  referred — the 
substitution  of  external  for  internal  manipulation.  In  the  next 
place,  as  we  have  already  said,  detachment  of  the  placenta  is 
best  performed  by  the  uterus  itself,  and  should  always  be  left  to 
that  organ  unless  the  latter  fails  to  accomplish  it.  Further, 
manual  removal  causes  more  pain  to  the  patient  than  does 
expression.  Consequently,  we  may  regard  manual  removal  of 
the  placenta  as  an  operation  which  is  only  to  be  performed 
in  cases  in  which  expression  fails,  and  so  is  never  to  be  adopted 
in  normal  cases. 

Traction  upon  the  Cord. — The  placenta  can  also  be  removed 
by  traction  upon  the  umbilical  cord,  but  this  method  has  little 
to  recommend  it,  and  possesses  many  disadvantages.  In  former 
days,  it  was  extensively  practised  until  its  dangers  came  to  be 
recognised.  If  strong  traction  is  applied  to  the  cord  while  the 
placenta  is  still  adherent,  one  of  several  results  may  happen. 
First,  the  placenta  may  be  pulled  completely  away,  in  which  case 
no  great  harm  is  done  provided  that  the  detachment  is  not  prema- 
ture. Secondly,  large  portions  of  the  placenta  may  be  left 
behind,  necessitating  the  introduction  of  the  hand  for  their 
removal.  Lastly,  if  the  uterus  is  in  a  relaxed  state  when  the 
traction  is  made,  and  if  the  adhesions  between  it  and  the  placenta 
are  dense,  it  may  be  inverted — that  is  to  say,  the  fundus  may 
be  dragged  downwards  until  it  passes  through  the  uterine  orifice, 
the  uterine  body  turning  either  in  part  or  altogether  inside  out. 
This  is  a  most  serious  accident,  and  will  be  referred  to  later. 
The  removal  of  the  placenta  from  the  vagina  by  traction  upon 
the  cord  is  not  open  to  such  grave  objection,  and  possesses  the 
advantage  over  expression  that  it  is  less  painful.  However, 
it  is  difficult  to  be  certain  that  the  placenta  is  in  the  vagina, 
particularly  if  the  medical  attendant  is  inexperienced,  and  if  he 
happens  to  make  an  error  in  diagnosis  and  tries  to  drag  the 
placenta  from  the  uterus,  under  the  impression  that  he  is 
removing  it  from  the  vagina,  the  accidents  which  have  been  just 
referred  to  may  happen.  Traction  on  the  cord  is,  therefore,  a 
practice  with  which  it  is  better  to  entirely  dispense. 

Accordingly,  we  see  that  the  most  suitable  manner  in  which  to 

*  '  Ueber  die  Zweckmassigste  Methode  der  Entfernung  der  Nachgeburt.' 
Monatss.  f.  Geburt.,  1861,  vol.  xvii.,  pp.  274-292. 

f  Vide  also  an  article  by  the  author  : — '  The  Dublin  Method  of  Effecting  the 
Delivery  of  the  Placenta  '  (Trans.  Royal  Acad.  Med.  in  Ireland,  1900,  p.  305). 


THE  MANAGEMENT  OF  THE  THIRD  STAGE  355 

remove  the  placenta  from  the  vagina  in  normal  cases,  or  from  the 
uterus  in  cases  in  which  it  is  retained  there,  is  by  the  Dublin 
method.  If  the  Dublin  method  fails  to  procure  its  expulsion,  we 
must  then  introduce  the  hand  and  remove  the  placenta,  but  this 
procedure  is  an  obstetrical  operation,  and  will  be  described  under 
that  heading. 

As  we  have  already  referred  to  the  various  physical  signs 
which  show  that  the  placenta  has  passed  from  the  uterus  into 
the  vagina,  we  need  not  again  do  so. 

As  the  placenta  emerges  from  the  vagina,  the  nurse  receives  it 
in  her  hands,  and  supports  it  in  order  to  prevent  it  falling  suddenly 
on  to  the  bed,  and  perhaps  tearing  away  from  the  membranes 
which  have  not  yet  left  the  uterus.  At  the  same  time,  she  draws 
it  gently  downwards  in  such  a  manner  as  to  cause  the  membranes 
to  strip  off  the  interior  of  the  utenas  and  so  to  come  away.  It  is 
most  important  that  none  of  them  should  be  left  behind,  and  con- 
sequently this  process  must  be  carefully  accomplished.  If  the 
membranes  show  any  signs  of  breaking  off  short,  the  nurse  should 
stop  drawing  on  the  placenta  and  take  the  membranes  themselves 
in  her  fingers  as  high  as  she  can  reach,  and  pull  them  gently 
downwards  for  an  inch  or  so.  She  should  then  take  a  fresh  grip 
of  them  and  draw  down  again,  and  so  on  until  they  have  all  come 
away.  If  a  piece  of  membrane  is  left  behind  hanging  from  the 
uterine  orifice  it  should  be  caught  in  a  forceps — as  it  is  difficult  to 
obtain  a  firm  hold  with  the  fingers,  and  pulled  away,  or,  if  that  is 
impossible,  broken  off  inside  the  orifice.  In  no  case  should  a  piece 
of  membrane  be  allowed  to  remain  hanging  into  the  vagina,  but, 
if  a  small  portion  is  left  behind  in  the  uterus,  it  is  of  no  great 
consequence,  and  it  may  be  left  there  to  come  away  in  the  lochia. 

The  placenta,  with  its  adherent  membranes,  must  then  be 
placed  upon  a  flat  dish  in  order  that  we  may  thoroughly  examine 
them  with  a  view  to  determine  whether  any  pieces  have  been 
left  behind  in  the  uterus.  As  the  placenta  is  usually  inverted  into 
the  membranes  and  the  ovi-sac  turned  inside  out,  it  is  well  to 
commence  by  turning  the  latter  right  again.  The  uterine  surface 
of  the  placenta  is  then  inspected  in  order  to  determine  whether 
any  cotyledons  are  missing.  It  frequently  happens  that  there 
are  deep  gashes  in  the  placental  substance  which  have  occurred 
during  expulsion,  and  which,  at  first  sight,  appear  to  point  to 
a  portion  being  missing.  If,  however,  the  torn  edges  are  pressed 
into  place  they  will  come  together  if  the  condition  is  merely  due 
to  a  tear,  while  if  a  portion  has  been  left  behind  there  will  still  be 
a  gap  in  the  placental  substance.  In  examining  the  membranes 
our  attention  must  be  directed  to  two  points.  First,  we  must 
ascertain  whether  both  membranes  are  complete.  We  cannot 
be  quite  certain  that  small  pieces  have  not  been  left  behind,  but 
if  large  pieces  are  missing  we  can  always  easily  recognise  the  fact. 
Secondly,  we  must  ascertain  the  number  of  openings  in  the  mem- 
branes.    Usually,  there  is  but  one  opening — namely,  that  through 

23—2 


356  THE  PHYSIOLOGY  OF  LABOUR 

which  the  foetus  has  passed,  and  the  presence  of  a  second  open- 
ing is  of  considerable  importance,  particularly  if  it  is  not  merely 
a  tear  in  the  membranes,  but  represents  a  missing  portion.  Such 
an  opening  may  be  due  to  the  tearing  away  of  a  piece  of  mem- 
brane which  was  more  than  usually  adherent  to  the  uterine  wall, 
or  it  may  be  caused  by  a  more  important  condition,  the  presence 
of  a  second  placenta — a  placenta  succenturiata — which  has  been  left 
behind.  If  the  latter  is  the  true  cause,  we  shall  find,  on  examining 
the  placenta  or  cord,  bloodvessels  which  have  been  torn  across 
and  which  were  running  to  this  second  placenta.  In  such  cases, 
or  in  cases  in  which  a  portion  of  the  placenta  itself  has  been  left, 
we  must  examine  the  interior  of  the  uterus  manually  and  remove 
all  retained  fragments. 

As  soon  as  the  delivery  of  the  placenta  and  membranes  is 
complete,  the  final  step  consists  in  washing  away  all  blood -stains 
from  the  genitals  and  thighs,  in  removing  the  soiled  linen,  and 
in  applying  the  napkin  and  binder.  For  washing  the  patient  at 
this  stage  a  weak  solution  of  lysol  is,  perhaps,  best  (half  a  drachm 
to  the  pint).  The  draw-sheet  and  small  mackintosh  are  removed, 
and  a  dry  and  warm  draw-sheet  substituted,  as  is  also  done  in 
the  case  of  the  patient's  night-gown  •  if  soiled.  The  napkin, 
which  had  been  previously  placed  in  a  solution  of  corrosive 
sublimate,  as  has  been  mentioned,  is  wrung  as  dry  as  possible 
and  applied  to  the  vulva.  Unless  the  patient  complains  of  feeling 
chilled,  the  napkin  may  be  applied  wrung  out  of  cold  solution,  as 
it  is  usually  more  soothing  when  thus  used.  It  should  reach 
upwards  under  the  patient's  hips  behind  and  over  the  abdomen 
in  front.  The  binder  is  next  applied.  It  should  reach  from  the 
level  of  the  ensiform  cartilage  to  the  middle  of  the  thighs,  and 
should  be  fastened  with  four  or  five  surgical  pins.  The  first  of 
these  is  placed  below  the  level  of  the  trochanters,  the  second  just 
above  the  trochanters,  the  third  at  the  level  of  the  umbilicus,  and 
the  fourth  close  to  the  top  of  the  binder.  Particular  care  must 
be  taken  to  see  that  the  pressure  of  the  binder  is  so  directed  that 
the  uterus  is  pressed  downwards  into  the  pelvis  and  does  not  rise 
above  the  level  of  the  third  pin.  In  the  case  of  a  patient  with  a 
very  flaccid  or  fat  abdomen,  it  is  well  to  apply  a  small  pad  made 
of  one  or  two  towels,  folded  in  half  three  times,  above  the  fundus 
and  between  the  third  and  fourth  pin  of  the  binder. 

We  may  now  sum  up  the  management  of  the  third  stage 
in  a  few  words.  As  soon  as  the  infant  is  born  turn  the  patient 
on  her  back  and  place  the  hand  upon  the  fundus  for  the  purpose 
of  controlling  it.  If  uterine  contractions  are  infrequent  and 
weak  their  occurrence  can  be  stimulated  by  gentle  friction  of 
the  fundus.  So  long  as  no  haemorrhage  occurs,  we  wait  until  the 
placenta  is  detached  and  expelled  from  the  uterus,  and  we  then 
express  it  from  the  vagina  by  the  Dublin  method.  If  it  should 
not  be  expelled  from  the  uterus  within  an  hour  of  the  birth  of  the 
foetus,  we  first  attempt  to  express  it,  and,  if  this  fails,  we  remove 


ANESTHESIA   DURING  LABOUR 


357 


it  manually.     The   patient  is   then  washed  and  the  napkin  and 
binder  applied. 

The  patient  is  now  comfortably  settled,  and  labour  may  be 
considered  to  be  over.  The  obstetrician  should  not,  however, 
as  a  rule,  leave  the  house  for  a  full  hour  after  the  birth  of  the 
placenta. 


Anaesthesia  During  Labour. 

The  beneficial  effect  of  the  use  of  anaesthetics  during  labour  has 
come  to  be  so  well  recognised  that  it  is  no  longer  necessary  to 
discuss  whether  their  use  is  justifiable  or  not.  In  obstetrical 
practice,  ether  is  for  many  reasons  but  little  used,  its  place  being 
entirely  taken  by  chloroform,  save  in  the  rare  instances  in  which 
the  condition  of  the  patient's  heart  forbids  the  use  of  the  latter 
drug.  Ether  is  more  difficult  to  administer,  as  it  requires  a  more 
cumbersome   apparatus,  the  inflammable   nature    of  its   vapour 


Fig.  200. — Schimmelbusch's  Chloroform  Mask. 

renders  its  use  dangerous  in  the  neighbourhood  of  an  artificial 
light,  and  its  after-effects  upon  the  patient  are  more  unpleasant. 

Chloroform,  however,  also  must  never  be  administered  in  the 
immediate  neighbourhood  of  a  candle  or  lamp,  as  such  a  light 
decomposes  it  into  chlorine  gas  and  hydrochloric  acid,  inhalation 
of  which  may  set  up  a  serious  form  of  pneumonia. 

Two  forms  of  anaesthesia  are  used  in  obstetrical  practice — 
surgical  anaesthesia  and  obstetrical  anaesthesia. 

Surgical  Anaesthesia. — In  surgical  anaesthesia,  the  anaesthetic  is 
administered  to  a  sufficient  extent  to  produce  complete  uncon- 
sciousness and  abolition  of  reflexes.  This  degree  of  anaesthesia  is 
required  in  the  performance  of  various  obstetrical  operations.  The 
mode  of  administration  does  not  differ  in  any  particular  from  the 
mode  used  in  surgery,  and  the  chloroform  is  best  administered 
upon  Skinner's  or  Schimmelbusch's  mask  (v.  Fig.  200),  or  if 
necessary  on  a  pocket-handkerchief. 


358  THE  PHYSIOLOGY  OF  LABOUR 

Obstetrical  Anaesthesia. — In  obstetrical  anaesthesia,  the  anaes- 
thetic is  only  administered  in  sufficient  quantity  to  produce  a 
blunting  of  sensation  without  complete  loss  of  consciousness.  This 
degree  is  of  use  in  ordinary  cases  of  labour,  when  the  patient's 
sufferings  are  considerable,  as  it  will  give  immediate  relief,  and  at 
the  same  time  will  not  interfere  with  the  course  of  labour  if  used 
at  the  proper  time.  To  obtain  obstetrical  anaesthesia,  chloroform 
may  be  dropped  on  a  Skinner's  mask  in  the  ordinary  manner, 
commencing  as  soon  as  there  is  any  sign  of  the  onset  of  a  con- 
traction, and  ceasing  as  soon  as  the  patient  is  obviously  not 
suffering.  The  patient  recovers  more  or  less  complete  conscious- 
ness between  the  contractions,  and  on  the  onset  of  the  next 
contraction  the  chloroform  is  again  administered  as  before.  A 
more  simple  means  of  obtaining  the  same  end  is  by  the  use  of 
Murphy's*  inhaler.  This  inhaler  (v.  Fig.  201)  consists  of  a  metal 
chamber  and  a  face-piece.  The  chamber  contains  a  small  piece 
of  sponge,  on  which  a  drachm  of  chloroform  is  poured.  The 
entrance  and  exit  of  air  are  regulated  by  two  rubber  valves,  so 
arranged   that    only   inspirations   pass    through    the   chloroform 


Fig.  201. — Murphy's  Chloroform  Inhaler. 

chamber.  In  the  original  pattern,  the  face-piece  was  made  to 
cover  the  mouth  only,  as  Murphy  considered  that  it  was  advisable 
to  allow  the  patient  to  breath  pure  air  through  the_  nose,  as  well 
as  chloroform-ladened  air  through  the  mouth.  This  precaution, 
however,  is  unnecessary,  and  in  practice  it  is  found  very  difficult 
to  get  a  patient  at  the  height  of  a  pain  to  breathe  sufficiently 
through  the  mouth  to  inhale  the  required  amount  of  vapour. 
Consequently,  a  face-piece  which  covers  both  mouth  and  nose  is 
more  suitable.  The  working  of  the  inhaler  is  very  simple.  A 
drachm  of  chloroform  is  poured  upon  the  sponge,  the  inhaler  is 
then  given  to  the  patient  to  hold,  and  she  is  told  to  place  it  over 
her  mouth  and  breathe  through  it  every  time  she  feels  a  pain 
commencing.  As  soon  as  she  has  inhaled  sufficient  to  cause 
partial  loss  of  consciousness  she  drops  the  inhaler,  and  the  effect 
of  the  chloroform  inhaled  will  last  as  long  as  the  pain  of  the 
contraction.  Chloroform  can  be  administered  in  this  manner  for 
a  considerable  time  without  interfering  in  any  way  with  th< 
course  of  labour.     Indeed,  the  dread  of  increasing  the  pain  some 

*  '  Principles  and  Practice  of  Midwifery,'  second  edition,  p.  576. 


e 


THE  USE  OF  ERGOT  359 

times  prevents  a  patient  from  bearing  down,  and,  consequently, 
the  induction  of  obstetrical  anaesthesia  tends  to  increase  rather 
than  to  lessen  the  expelling  forces.  Obstetrical  an&esthesia  may 
be  induced  in  any  case  in  which  there  is  no  contra-indication  to 
the  use  of  chloroform,  and  in  which  the  sufferings  of  the  patient 
are  considerable.  It  should  not,  however,  save  under  the  most 
exceptional  circumstances,  be  commenced  until  the  patient  has 
passed  into  the  second  stage  and  is  actively  bearing  down,  as,  if 
it  is  commenced  at  an  earlier  period,  it  may  have  to  be  continued 
longer  than  is  advisable. 

As  is  mentioned  elsewhere,  there  is  no  reason  to  apprehend 
any  toxic  effect  on  the  foetus  from  the  administration  of  either 
chloroform  or  ether,  unless  the  maternal  anaesthesia  is  very  deep 
and  long  continued  (Ballantyne).*  According  to  Diihrssen,t  a 
limit  of  four  hours  should  never  be  exceeded,  but  even  this 
period  seems  to  be  too  long. 

The  Use  of  Ergot. 

It  may  not,  perhaps,  be  out  of  place  to  devote  a  few  lines  to 
the  discussion  of  the  use  of  ergot  of  rye  during  labour.  The 
physiological  effect  of  ergot  as  far  as  the  uterus  is  concerned 
appears  to  be  a  lessening  of  venous  tension  and  an  increased 
venous  dilatation,  which  produce  an  arterial  anaemia  of  the  uterus 
and  its  nerve  centres,  a  condition  which  in  turn  increases  the 
duration  and  intensity  of  the  uterine  contractions  (Wernich).  If 
a  sufficient  dose  is  given,  the  interval  between  the  contractions 
disappears,  and  a  condition  of  tonic  contraction  occurs.  Further- 
more, it  is  stated  by  Lombe  Atthill,  J  and  is  constantly  proved  in 
practice,  that  ergot  will  not  cause  uterine  action  unless  such 
action  has  already  commenced  ;  that,  in  other  words,  it  will 
increase  the  force  and  frequency  of  existing  contractions,  but 
that  it  will  not  cause  their  onset.  The  principal  effect  of  ergot  on 
the  uterine  contractions  of  labour  is  to  increase  their  force,  and 
to  tend  to  make  them  tonic  instead  of  intermittent.  The  former 
of  these  properties  may  in  many  cases  be  of  great  value,  but  the 
second  can  only  be  made  use  of  under  certain  well-specified 
conditions.  As  we  know,  the  intermittent  nature  of  the  uterine 
contractions  is  of  paramount  importance  in  labour.  If  there  was 
no  interval  between  the  contractions,  the  foetus  would  not  receive 
its  proper  supply  of  oxygen  owing  to  the  obstruction  offered  to 
the  placental  circulation,  the  patient  would  rapidly  become  worn 
out  and  unable  to  bear  down,  and  uterine  retraction  would  occur 
with  such  rapidity  that,  before  the  necessary  dilatation  of  the 
orifice  and  the  soft  parts  had  occurred,  the  lower  uterine  segment 

*  Op.  cit. 

t  '  A  Manual  of  Obstetric  Practice,'  English  edition,  p.  237. 
X  'Observations  on  the  Anticipation  of  Post-partum  Haemorrhage,'    etc. 
(Trans.  Royal  Acad.  Med.  Ireland,  1897,  p.  338). 


360  THE  PHYSIOLOGY  OF  LABOUR 

might  become  overdistended  and  rupture.  Consequently,  so  long 
as  intermittent  contractions  of  the  uterus  are  necessary  to  the 
normal  continuance  of  labour,  we  cannot  administer  ergot  to  the 
patient.  When,  however,  labour  has  so  far  advanced  that  the 
occurrence  of  tonic  contractions  is  advisable,  ergot  may  be 
administered  in  fairly  large  doses.  This  period  is  reached  when 
the  uterus  is  empty.  In  the  first  stage  of  labour,  ergot  may  not, 
perhaps,  increase  the  pressure  upon  the  foetus  and  placenta  to  a 
dangerous  extent,  inasmuch  as  the  liquor  amnii  is  still  present, 
but  it  will  delay  the  dilatation  of  the  uterine  orifice.  In  the 
second  stage,  it  will  materially  effect  the  fcetal  circulation  by 
causing  continuous  pressure  upon  the  placenta  and  cord,  and 
may  cause  the  rupture  of  the  uterus  if  there  is  any  obstacle  to 
the  speedy  expulsion  of  the  foetus.  In  the  first  part  of  the  third 
stage,  it  will  tend  to  cause  irregular  contractions  of  the  uterus  and 
the  incarceration  of  the  placenta,  but,  during  and  after  the  second 
part  of  this  stage,  when  the  uterus  is  empty,  its  action  will  be 
wholly  beneficial.  From  that  time  on,  the  occurrence  of  tonic 
contraction  is  most  desirable,  as  it  prevents  post-partum  haemor- 
rhage and  the  accumulation  of  clots  in  the  uterine  cavity,  and 
furthers  the  process  of  involution. 

Many  obstetricians  recommend  the-  routine  administration  of 
ergot  at  this  period  of  labour,  and  there  is  no  objection  that  we 
can  see  to  such  a  custom ;  it  may  not  be  always  necessary,  but  it 
can  do  no  harm.  If  the  obstetrician  lives  at  some  distance,  he 
will  have  his  mind  at  greater  ease  when  leaving  his  patient  if  he 
knows  that  firm  contractions  have  occurred  and  will  continue. 
Whatever  may  be  said  as  to  its  routine  use,  ergot  is  of  value  in 
cases  of  insufficient  contraction  of  the  uterus  after  the  third  stage 
owing  to  muscular  weakness,  and  possibly  in  cases  of  subinvolution 
of  the  uterus. 

Ergot  may  be  administered  by  the  mouth  or  hypodermically. 
Ergot  administered  by  the  mouth  takes  from  ten  to  twenty 
minutes  to  produce  its  effect,  while  given  hypodermically  it  acts 
in  five  minutes  or  less.  By  the  mouth  it  may  be  given  in  the 
form  of  the  liquid  extract  in  doses  of  from  one  to  two  drachms. 
Hypodermically,  it  may  be  given  as  citrate  of  ergotinine  or  as  the 
liquid  extract,  in  doses  of  up  to  ^  grain  of  the  former,  and  up  to 
a  drachm  of  the  latter.  If  administered  in  this  manner,  it  must 
be  injected  deeply  into  a  muscle  and  not  subcutaneously. 


CHAPTER  V 

CEPHALIC  PRESENTATIONS  (continued)— FACE 

PRESENTATION,  BROW  PRESENTATION,  FONTANELLE 

PRESENTATION 

Face  Presentation — Frequency — yEtiology — Positions — Diagnosis — Mechan- 
ism— Abnormal  Mechanism,  Reversed  Rotation  of  Head — Moulding — 
Management,  Flexion  by  External  Manipulations,  by  Combined  External 
and  Internal  Manipulations — Prognosis.  Brow  Presentation — Frequency 
—  ^Etiology —  Positions  —  Diagnosis — Mechanism — Moulding — Manage- 
ment— Prognosis.  Anterior  Fontanelle  Presentation — ^Etiology — Posi- 
tions —  Diagnosis  —  Mechanism  —  Treatment  —  Prognosis.  Posterior 
Fontanelle  Presentation— ^Etiology — Positions — Diagnosis — Mechanism 
— Moulding — Treatment — Prognosis. 

FACE  PRESENTATION 

A  face  presentation  is  the  term  applied  to  the  presentation  after 
full  extension  of  the  head,  as  a  result  of  which  the  face  lies 
lowest. 

Frequency. — The  frequency  of  face  presentations  appears  to  vary 
considerably  in  the  practice  of  different  obstetricians.  Pinard  and 
Lepage,  at  the  Clinique  Baudelocque,  met  with  26  cases  amongst 
10,398  labours,  or  a  proportion  of  1  in  399.  At  the  Rotunda 
Hospital,  53  cases  occurred  amongst  19,293  patients,  or  a  propor- 
tion of  1  in  364-01.  Spiegelberg,  from  German  statistics,  estimates 
the  proportion  at  1  in  324.  Pinard,  at  the  Maternite  and  Lari- 
boisiere  Hospitals,  met  with  374  cases  amongst  92,026  labours, 
or  a  proportion  of  1  in  247.  Churchill,  out  of  nearly  250,000 
cases,  estimates  the  proportion  at  1  in  231.  The  statistics  of 
Guy's  Hospital  show  a  proportion  of  1  in  303  amongst  49,145 
cases.     Usually,  the  average  proportion  is  given  as  1  in  250. 

Aetiology. — A  face  presentation  is  almost  invariably  a  secondary 
or  resultant  presentation,  the  result  of  some  interference  with 
the  mechanism  of  a  vertex  presentation.  In  exceptional  cases, 
the  alteration  in  the  attitude  of  the  foetus  may  be  primary — that 
is  to  say,  may  be  present  before  labour  commences,  owing  to 
some  deformity  which  is  present  either  in  the  foetus  or  in  the 
uterus,  and  which  prevents  the  former  from  assuming  its  normal 
attitude.  We  must,  therefore,  classify  the  causes  of  face  pre 
sentation  according  as  they  produce  that  presentation  primarily 

361 


362 


THE  PHYSIOLOGY  OF  LABOUR 


Fig.  202. — First  Face  Presentation,  the  Back  in  Front.     (Farabceuf.) 


Fig.  203. — First  Face  Presentation,  with  the  Back  in  Front. 
The  face  presenting  at  the  brim,  as  felt  by  vaginal  examination. 


THE  CAUSES  OF  FACE  PRESENTATION 


363 


Fig.  204.— First  Face  Presentation,  the  Back  Behind.     (Faraboeuf.) 


Fig.  205. — First  Face  Presentation,  with  the  Back  Behind. 
The  face  presenting  at  the  brim,  as_felt  by  vaginal  examination. 


364 


THE  PHYSIOLOGY  OF  LABOUR 


or  secondarily.  The  causes  which  produce  primary  presentation 
of  the  face  are  few  in  number.  Tumours  about  the  neck  of  the 
foetus,  such  as  a  greatly  enlarged  thyroid,  may  force  the  head  into 
a  position  of  extension.  Hydrothorax  may  have  the  same  effect. 
An  anencephalous  foetus — i.e.,  a  foetus  in  which  the  cranial  bones 
are  defective — may  present  by  the  face  owing  to  shortness  or  com- 
parative absence  of  neck.     Tumours,  situated  so  low  in  the  uterus 


Fig.  206.— Second  Face  Presentation,  the  Back  in  Front.    (Farabceuf. ) 

as  to  interfere  with  the  normal  accommodation  between  the  head 
and  the  lower  uterine  segment,  may  also  cause  extension. 

The  causes  which  produce  a  secondary  face  presentation  are 
more  numerous.  If  we  recall  the  factors  which  bring  about  in- 
creased flexion  in  a  vertex  presentation,  we  shall  more  readily 
understand  the  factors  which  bring  about  the  opposite  condition. 
The  first  factor  in  the  production  of  flexion  is  the  relation 
between  the  shape  of  the  head  and  the  shape  of  the  pelvis. 
The   occiput    is   sheer  in  outline  and   tends  to  slip  readily  past 


THE  CAUSES  OF  FACE  PRESENTATION 


365 


the  pelvic  brim,  while  the  sinciput,  on  the  other  hand,  is  more 
prominent  and  consequently  meets  with  greater  resistance  from 
the  pelvic  brim.  As  a  result,  the  occiput  descends  more  rapidly 
than  the  sinciput.  The  second  factor  is  to  be  found  in  the  fact 
that  the  foetal -axis  pressure  acts  upon  the  base  of  the  skull 
at  a  point  nearer  to  the  occiput  than  the  sinciput  and,  conse- 
quently, exerts  more  force  upon  the  former  and  drives  it  down- 
wards more  rapidly.  We  can  thus  readily  understand  that 
anything  that  increases  the  resistance  to  the  descent  of  the 
occiput,  or  that  makes  the  fcetal-axis  pressure  act  with  greater 
force  upon  the  sinciput  than  upon  the  occiput,  will  tend  to  cause 
a  more  rapid  descent  of  the  sinciput  than  of  the  occiput,  and  this 
descent  will,  in  the  majority  of  cases,  continue  until  the  head  has 


Fig.  207. — Second  Face  Presentation,  with  the  Back  in  Front. 
The  head  presenting  at  the  brim,  as  felt  by  vaginal  examination. 


come  into  a  position  of  stable  equilibrium — that  is  to  say,  until 
the  occiput  is  in  contact  with  the  back  of  the  foetus  and  the  face 
presents.  The  usual  causes  of  increased  resistance  to  the  descent 
of  the  occiput  are  contraction  of  the  pelvis  and  obliquity  of  the 
uterus,  and  these  causes  are  rendered  more  effective  by  associa- 
tion with  a  large  foetus.  In  a  pelvis  which  is  contracted  in  its 
antero-posterior  diameter,  the  head  tends  to  move  towards  the  side 
at  which  the  occiput  lies  as  soon  as  uterine  contractions  com- 
mence, and  the  result  of  this  may  be  that  the  occiput  projects 
slightly  beyond  the  brim,  and  that,  consequently,  its  descent  is 
retarded.  Similarly,  if  the  uterine  axis  is  deflected  away  from 
the  side  at  which  the  occiput  lies,  the  contractions,  instead  of 
driving  the  foetus  into  the  pelvic  cavity,  tend  to  drive  the  occiput 


366 


THE  PHYSIOLOGY  OF  LABOUR 


against  the  brim  and  so  to  retard  its  descent  (Matthews  Duncan). 
A  rarer  cause  of  face  presentation  will  be  found  in  a  dolicho- 
cephalic head — that  is,  a  head  in  which  the  occiput  is  unduly 
prominent.  Such  a  condition  will  not  only  cause  increased 
obstruction  to  the  descent  of  the  occiput,  but  will  also  alter  the 
effect  of  the  fcetal-axis  pressure  upon  the  position  of  the  head, 
inasmuch  as  now,  owing  to  the  increased  length  of  the  occiput, 
this  pressure  may  act  upon  a  point  of  the  head  which  is  nearer 


Fig.  208. — Second  Face  Presentation,  the  Back  Behind.     (Farabceuf.) 

to  the  sinciput  than  to  the  occiput.  The  question  of  the  relation 
of  a  dolicho- cephalic  head  to  face  presentations  cannot  be  regarded 
as  quite  settled.  There  is  no  doubt  that  if  there  is  such  a  thing 
as  a  dolicho-cephalic  head  in  a  foetus  in  utero  it  will  tend  to  cause 
a  face  presentation  (Hecker*) ;  but,  on  the  other  hand,  the  dolicho- 
cephalic head,  which  an  infant  born  as  a  face  presentation  usually 
possesses,  is,  in  all  probability,  most  frequently  the  result  of 
moulding.     There  is    very   little   proof  that   a   true   or  primary 

*  Schadelform  bei  Gesichtslagen,  1869,  and  Archiv  f.  Gynak.,  II.;  429. 


THE  DIAGNOSIS  OF  FACE  PRESENTATION  367 

dolicho-cephalus  exists,  and,  consequently,  too  much  stress  need 
not  be  laid  upon  it  as  a  cause  of  face  presentation. 

In  addition  to  the  foregoing  causes  of  face  presentation,  there 
are  others  whose  mode  of  action  it  is  difficult  to  explain.  Strictly 
speaking,  the  causes  to  which  we  refer  are  causes,  not  of  face 
presentation  in  particular,  but  of  any  abnormal  presentation,  and 
produce  their  effect  by  altering  the  normal  adaptation  which 
exists  between  the  foetus,  as  a  whole,  and  the  uterine  cavity,  or 
between  the  foetal  head  and  the  lower  uterine  segment.  They  are 
as  follows  :— Hydramnios,  twins,  macerated  foetus,  pluriparity, 
and  a  large  foetus. 

Positions. — In  face  presentation,  as  in  vertex  presentation,  the 
foetus  can  lie  in  one  of  two  positions  according  as  the  back  is 
directed  to  the  left  or  to  the  right.  Each  of  these  positions  can 
again  be  divided  into  two  more,  according  as  the  back  is  directed 
anteriorly  or  posteriorly.  Accordingly,  the  different  positions  can 
be  tabulated  as  follows  : — 

/  In  front,  first  position  of  Naegele,  sometimes  termed 

—.     .         ...        ',      ,   ,  right  mento-posterior,  or  shortly,  R.M.P. 

First  position,  back  to  ]         6  ^  ■" 

Behind,    fourth   position    of    Naegele,    right    mento- 
[     anterior,  or  R.M.A. 

1  In    front,    second   position   of    Naegele,    left    mento- 

Second  position,  back  1      "  ' 

Behind,  third  position  of  Naegele,  left  mento  anterior, 
or  L.M.A. 


to  the  right. 


It  will  be  noticed  that  each  of  these  positions  corresponds  with 
the  position  of  the  vertex  of  the  same  number.  For  instance, 
a  first  vertex  presentation  with  the  back  in  front — i.e.,  a  left 
occipito-anterior  position — becomes,  if  extension  of  the  head 
occurs,  a  first  position  of  the  face  with  the  back  in  front  or 
a  right  mento-posterior  position,  and  similarly  with  the  other 
positions.  The  indicator,  or  point  de  repere,  which  is  used  in 
Naegele's  classification,  is  in  vertex  presentation  the  occiput,  in 
face  presentation  the  chin. 

As  a  face  presentation  is,  in  the  great  majority  of  cases, 
secondary  to  a  vertex  presentation,  the  order  of  frequency  of  the 
different  positions  is  very  much  the  same.  The  first  position 
with  the  back  in  front — first  position  of  Naegele— is  the  most 
common  ;  the  second  position  with  the  back  behind — third  posi- 
tion of  Naegele  —  the  next  most  common  ;  while  the  other  positions 
are  rare.  Considerable  differences  of  opinion,  however,  exist  in 
the  minds  of  different  authorities  as  to  the  relative  frequency  of 
the  various  positions. 

Diagnosis. — The  diagnosis  of  face  presentation  can  be  made  by 
abdominal  palpation,  vaginal  examination,  and  auscultation. 

Abdominal  Palpation. — The  pelvic  pole  of  the  fcetus  is  found 
at  the  fundus  of  the  uterus,  and  is  recognised  by  the  characteristics 


368 


THE  PHYSIOLOGY  OF  LABOUR 


which  have  already  been  mentioned.  The  lie  of  the  foetus  is 
found  to  be  longitudinal,  with  the  back  towards  one  or  other  side, 
according  to  the  position.  If  the  back  is  posterior,  the  limbs  are 
felt  with  greater  distinctness  than  in  the  case  of  a  vertex  presenta- 
tion, owing  to  the  extension  of  the  head,  which  forces  the 
abdominal  wall  and  limbs  of  the  foetus  into  close  contact  with 
the  anterior  uterine  wall.  For  a  similar  reason,  if  the  back  is 
anterior  it  lies  at  a  deeper  level  in  the  uterus,  and  the  limbs  are 
felt  with  greater  difficulty  than  in  a  vertex.  The  head  is  found 
in  the  lower  pole  of  the  uterus,  if  it  has  not  passed  below  the 
brim.  The  occiput  forms  a  rounded  and  prominent  tumour,  which 
completely  fills  the  pelvic  brim  on  the  side  corresponding  to  the 
back  of  the  foetus.     The  chin  is  felt  as  a  small  tumour  '  like  an 


Fig.  209. — Second  Face  Presentation,  with  the  Back  Behind. 
The  face  presenting  at  the  brim,  as  felt  by  vaginal  examination. 


animal's  hoof  (Budin),  resting  on  the  brim  on  the  same  side  as 
the  limbs.  The  occiput  lies  at  a  higher  level  than  the  chin,  and 
the  groove  of  the  neck  runs  obliquely  in  a  corresponding  direction. 
If  the  head  has  passed  below  the  brim,  the  fingers  can  be  sunk 
deeply  into  the  pelvis  on  the  side  of  the  limbs,  while  on  the  side 
of  the  back  they  are  stopped  by  the  prominence  formed  by  the 
occiput.  Accordingly,  if  we  contrast  the  results  of  abdominal 
palpation  in  a  vertex  presentation  and  in  a  face  presentation,  we 
find  that,  whereas  in  a  vertex  the  posterior  aspect  of  the  body  and 
the  anterior  aspect  of  the  head  are  more  readily  palpated,  in  a 
face  presentation  the  anterior  aspect  of  the  body  and  the  posterior 
aspect  of  the  head  are  more  readily  palpated,  a  difference  which 
is,  of  course,  due  to  the  altered  attitude  of  the  foetus.     A  striking 


THE  DIAGNOSIS  OF  FACE  PRESENTATION 


369 


proof  of  the  close  apposition  of  the  anterior  surface  of  the  foetus 
to  the  uterine  wall  is  furnished  by  the  fact  that  in  face  presenta- 
tion it  has  been  found  possible  to  feel  the  pulsations  of  the  foetal 
heart  through  the  abdominal  wall  in  a  thin  subject  (Lefour, 
Fischer).  The  position  of  the  foetus  is  determined  by  noting  the 
side  at  which  the  limbs  are  situated. 

Vaginal  Examination. — At  the  commencement  or  labour  it  is 
difficult  to  reach  the  presenting  part  owing  to  its  high  situation  ; 
but    as  the  head  descends  the  face  is  felt,   and  can  be  readily 


Fig.  210. — Diagram  representing  the  Fcetus  as  felt  by  Abdominal 
Palpation  in  Face  Presentation. 

.,  First  position  of  face,  back  in  front;  B,  second  position  of  face,. back 
behind.  The  unshaded  portions  of  the  fcetus  are  those  that  are  felt 
most  distinctly. 


recognised  by  its  characteristic  outlines.  The  diagnostic  points 
are  the  supra-orbitai  ridges,  the  malar  bones,  and  the  mouth. 
The  latter  may  be  mistaken  for  the  anus,  but  if  its  relation  with 
the  other  landmarks  is  taken  into  consideration  a  mistake  will  not 
be  made.  It  has  been  recommended  to  pass  the  finger  into  the 
aperture  which  is  felt  in  order  to  make  a  diagnosis.  In  the  case 
of  the  mouth,  the  alveolar  ridges  and  the  tongue  are  felt,  the  lips 
do  not  grasp  the  fingers,  and  the  foetus  may  make  slight  sucking 

24 


370  THE  PHYSIOLOGY  OF  LABOUR 

efforts.  In  the  case  of  the  anus,  the  absence  of  alveolar  ridges 
and  tongue  is  noticed,  and  the  sphincter  ani  grasps  the  finger, 
which  on  being  withdrawn  may  be  covered  by  meconium. 
Although  we  have  given  this  method  of  making  a  diagnosis,  we 
altogether  condemn  such  a  practice,  as  the  efforts  at  sucking 
which  the  introduction  of  the  finger  into  the  mouth  may  cause 
will  very  probably  lead  to  the  inspiration  of  mucus  by  the  fcetus, 
and  so  to  subsequent  asphyxia. 

Later  in  labour,  when  a  large  caput  succedaneum  has  formed, 
the  difficulty  of  diagnosis  is  increased,  owing  to  the  obscuring  of 
the  outlines  of  the  presenting  part.  In  such  cases,  a  hurried 
examination  will  frequently  cause  a  face  to  be  taken  for  a  breech, 
or  vice  versa.  A  little  care  will,  however,  always  enable  us  to 
avoid  such  a  mistake,  as  by  passing  a  finger  upwards  to  one  or 
other  side  of  the  presenting  part,  in  the  case  of  a  face  presentation 
we  shall  reach  the  ear,  and  in  the  case  of  a  breech  presentation 
we  shall  reach  a  groove  between  a  thigh  and  the  body,  or  the 
groove  between  the  thighs  themselves. 

The  position  of  the  foetus  can  be  determined  by  noting  the 
relation  of  the  supra-orbital  ridges  and  the  mouth  to  the  pelvis. 
In  the  first  position,  the  supra-orbital  ridges  are  found  in  the  left 
half  of  the  pelvis,  the  mouth  in  the  right  half,  while  their  relation 
to  the  median  coronal  plane  of  the  pelvis  will  show  whether  the 
back  is  in  front  or  behind.  Similarly,  in  the  second  position  the 
supra-orbital  ridges  will  be  found  in  the  right  half  of  the  pelvis 
and  the  mouth  in  the  left  half. 

Auscultation. — From  what  has  been  already  said  of  the  attitude 
of  the  foetus,  it  will  be  seen  that  whereas  in  a  vertex  presentation 
the  foetal  heart  is  most  easily  heard  over  the  back  of  the  foetus,  in  a 
face  presentation  it  is  most  easily  heard  over  the  chest  (v.  Fig.  211). 
Further,  in  cases  in  which  the  back  of  the  foetus  is  directed 
anteriorly,  there  will  be  some  difficulty  in  hearing  the  heart ;  while 
when  the  limbs  are  anterior,  it  will  be  heard  with  unusual  distinct- 
ness. The  heart-sounds  will  be  heard  best  at  the  commencement 
of  labour  about  the  level  of  the  umbilicus  and  to  the  right  or  the 
left  of  the  middle  line,  according  as  the  foetus  lies  in  a  first  or  a 
second  position. 

Mechanism.  —  If  the'  general  principles,  which  govern  the 
mechanism  of  a  vertex  presentation,  have  been  mastered,  there 
will  be  no  difficulty  in  following  and  remembering  the  mechanism 
of  a  face  presentation.  As  soon  as  the  expulsion  of  the  foetus 
commences,  the  head  must  first  be  brought  into  a  position  of 
stable  equilibrium,  and  at  the  same  time  its  smallest  available 
diameters  must  be  brought  into  correspondence  with  the  diameters 
of  the  pelvic  brim.  This  proceeding,  which  in  the  case  of  a 
vertex  presentation  is  brought  about  by  flexion,  in  the  case  of  a 
face  is  brought  about  by  extension.  Then,  as  the  head  descends, 
it  must  rotate  in  order  to  keep  its  diameters  in  correspondence 
with  the  most  suitable  diameters  of  the  pelvic  cavity  and  outlet ; 


THE  MECHANISM  OF  FACE  PRESENTATION 


371 


and,  accordingly,  internal  rotation  takes  place  as  in  a  vertex 
presentation,  save  that  in  the  latter  the  occiput  under  normal 
circumstances  rotates  in  front,  in  a  face  presentation  the  chin 
rotates  in  front.  Next,  in  order  that  the  head  may  follow  the 
pelvic  curve  and  emerge  through  the  vulva,  it  must  move 
forwards  under  the  symphysis.      This  movement,  which  in  the 


Fig.  2ii. — Site  of  Maximum  Intensity  of  Heart-Sounds  when  the 
Head  is  extended.     (Bumm. ) 


case  of  a  vertex  presentation  is  obtained  by  extension,  in  the 
case  of  a  face  presentation  is  obtained  by  flexion.  Finally, 
after  the  birth  of  the  head,  restitution  must  take  place,  in  order 
to  bring  back  the  head  to  its  normal  relation  to  the  shoulders, 
and  external  rotation  proper  must  occur  in  consequence  of  the 
internal  rotation  of  the  shoulders  from  one  or  other  oblique 
diameter  into  the  antero-posterior  diameter  of  the  outlet.     We 

24—2 


372  THE  PHYSIOLOGY  OF  LABOUR 

thus  see  that  if,  in  the  mechanism  of  a  vertex  presentation,  we 
substitute  extension  for  flexion,  flexion  for  extension,  and  the  chin 
for  the  occiput,  we  get  the  mechanism  of  a  face  presentation,  and 
this  we  shall  now  describe  in  greater  detail. 

Descent. — Under  the  influence  of  the  uterine  contractions  the 
head  descends  into  the  pelvic  brim,  with  its  antero-posterior 
diameters  corresponding  to  the  oblique  diameter,  or,  according  to 


Fig.  212. — The  Mechanism  of  First  Face  Presentation. 
The  head  has  passed  the  brim  and  extension  is  complete. 

some  authorities,  to  the  transverse  diameter  of  the  brim.     As  the 
head  descends  extension  occurs. 

Extension. — The  second  act  in  the  mechanism  of  a  face  pre- 
sentation is  the  completion  of  extension,  the  result  of  which  is  to 
bring  the  occiput  into  contact  with  the  back  of  the  foetus,  and  to 
make  the  cervico-bregmatic  diameter — or,  according  to  some, 
the   cervico-frontal    diameter  —  the   greatest   engaging   diameter 


THE  MECHANISM  OF  FACE  PRESENTATION 


373 


(v.  Fig.  212).  The  cause  of  the  completion  of  extension  is  very 
obvious.  Once  the  head  has  reached  such  an  attitude  that  its 
posterior  projection  is  greater  than  its  anterior  projection,  the 
fcetal-axis  pressure,  acting  through  the  condyles,  tends  to  increase 
the  extension  present.  Further,  owing  to  the  shape  of  the  head 
when  in  a  position  of  partial  extension,  the  resistance  offered  by 
the  sides  of  the  pelvis  to  the  descent  of  the  vertex  and  occiput  is 


Fig.  213. — The  Mechanism  of  First  Face  Presentation. 
The  head  has  reached  the  pelvic  floor  and  internal  rotation  has  commenced. 

greater  than  that  offered  to  the  descent  of  the  chin,  and,  conse- 
quently, the  latter  descends  more  rapidly. 

Internal  Rotation.- -The  third  act  consists  in  the  anterior  rota- 
tion of  the  chin.  At  the  completion  of  extension,  the  head. was 
advancing  with  the  cervico-bregmatic  diameter  corresponding  to 
one  of  the  oblique  diameters  and  with  the  chin  lowest,  and  now, 
in  consequence  of  internal  rotation,  the  cervico-bregmatic  diameter 


374  THE  PHYSIOLOGY  OF  LABOUR 

corresponds  with  the  antero-posterior  diameter  of  the  pelvic  out- 
let, and  the  chin  comes  to  lie  beneath  the  symphysis  (v.  Fig.  214). 
If  the  chin  originally  lay  at  the  posterior  end  of  either  oblique 
diameter — i.e.,  in  either  the  first  or  second  position  of  Naegele — 
the  head  rotates  through  three-eighths  of  a  circle  ;  if  it  originally 
lay  at  the  anterior  end — i.e.,  in  either  the  third  or  fourth  position 
of  Naegele — the  head  rotates  through  one-eighth  of  a  circle. 
The  anterior  rotation  of  the  chin  is  in  obedience  to  the  general 
law  which  governs  internal  rotation,  that  whatever  portion  of  the 
presenting  part  lies  lowest  rotates  in  front  under  the  influence  of 
the  pelvic  floor.  If  the  forehead  lies  lowest,  then  it  will  rotate  in 
front,  and  one  of  the  most  serious  complications  of  labour  results. 
Internal  rotation  occurs  later  in  face  presentations  than  in  a 
vertex  presentation,  as,  on  account  of  their  length,  the  posterior 
vertical  diameters  of  the  head  must  have  passed  the  brim  before 
it  can  occur. 

Flexion. — The  fourth  act  consists  in  the  occurrence  of  flexion 
by  means  of  which  the  head,  pivoting  round  the  lower  margin  of 
the  symphysis,  is  born.  The  face  proper  appears  first,  then  the 
forehead,  the  bregma,  the  vertex,  and  lastly  the  occiput.  The 
cause  of  flexion  is  to  be  found  in  the  fact  that  as  soon  as  the  chin 
comes  to  lie  beneath  the  pubic  arch  it  is  practically  free  from  all 
pressure  from  above,  while  the  weight  of  the  uterine  contractions 
is  transmitted  to  the  occiput,  thus  driving  it  downwards  and 
forwards  over  the  pelvic  floor. 

External  Rotation. — The  fifth  act  is  made  up  of  restitution  and 
external  rotation  proper,  and  there  is  in  it  no  difference  of  im- 
portance between  the  mechanism  of  a  face  presentation  and  that 
of  a  vertex.  Restitution  carries  the  chin  back  to  the  side  at 
which  it  originally  lay,  and  external  rotation  proper,  the  result 
of  internal  rotation  of  the  shoulders,  carries  it  on  in  the  same 
direction. 

The  foregoing  description  is  a  general  one,  and  applies  to  the 
different  positions  of  the  foetus.  It  may  now  be  well  to  describe 
the  mechanism  of  each  position  in  a  few  words. 

First  Position,  Back  to  the  Left. — In  the  first  position,  with  the 
back  in  front,  first  position  of  Naegele,  right  mento-posterior,  the 
foetal  head  enters  the  pelvis  with  a  diameter  between  the  mento- 
occipital  and  the  cervico-bregmatic  diameters  corresponding  to 
the  right  oblique  diameter  of  the  pelvis.  Descent  and  extension 
then  occur,  and  the  cervico-bregmatic  diameter  becomes  the 
engaging  diameter.  The  head  continues  to  descend  with  the 
chin  lying  lowest,  and  as  soon  as  the  pelvic  floor  is  reached 
internal  rotation  occurs,  and  the  chin,  which  up  to  this  lay  at  the 
posterior  end  of  the  right  oblique  diameter,  rotates  through  three- 
eighths  of  a  circle,  and  comes  to  lie  under  the  pubic  arch.  The 
shoulders,  which  first  lay  in  the  left  oblique  diameter  of  the 
pelvis,  follow  part  of  this  movement  and  rotate  into  the  right 
oblique.     Flexion  next  occurs,  and  the  face,  vertex,  and  occiput  in 


THE  MECHANISM  OF  FACE  PRESENTATION 


375 


turn  appear  from  above  the  perinseum.  As  soon  as  the  head  is 
free  restitution  takes  place,  and  the  chin  rotates  to  the  right  through 
one-eighth  of  a  circle.  Finally,  as  the  shoulders  descend,  their 
internal  rotation  takes  place,  and  the  anterior  shoulder,  which 
corresponded  to  the  anterior  end  of  the  right  oblique  diameter, 
rotates  in  front  and  lies  behind  the  symphysis,  causing  a  corre- 
sponding external  rotation  of  the  chin  to  the  right  through  another 


Fig.  214. — The  Mechanism  of  First  Face  Presentation. 
Internal  rotation  is  complete,  and  the  chin  lies  below  the  symphysis. 

eighth  of  a  circle,  so  that  it  points  towards  the  mother's  right 
thigh.     The  shoulders  and  trunk  are  then  born. 

In  the  first  position,  with  the  back  behind — fourth  position  of 
Naegele,  right  mento  anterior — the  head  enters  the  brim,  with 
the  diameter  between  the  mento-occipital  and  the  cervico-breg- 
matic  diameters,  corresponding  to  the  left  oblique  diameter  of  the 
pelvis.  Descent  and  extension  occur,  and  the  cervico-bregmatic 
diameter  becomes  the  engaging  diameter.  Internal  rotation 
occurs  through  one-eighth  of  a  circle,  and  brings  the  chin  from  the 
anterior  end  of  the   left   oblique  diameter  to  lie  under  the  sym- 


376 


THE  PHYSIOLOGY  OF  LABOUR 


physis.  Flexion  occurs  as  before,  the  head  is  born,  and  restitu- 
tion follows.  Finally,  the  shoulders,  which  engaged  in  the  right 
oblique  diameter,  rotate  into  the  antero-posterior  diameter,  and 
at  the  same  time  external  rotation  proper  carries  the  chin  back 
again  to  point  towards  the  mother's  right  thigh. 

Second  Position,  Back  to  the  Eight. — In  the  second  position, 
with  the  back  to  the  front — second  position  of  Naegele,  left 
mento-posterior — the  foetal  head  enters  the  pelvis,  with  a  diameter 
between  the  mento-occipital  and  the  cervico-bregmatic  diameters, 
corresponding  to  the  left  oblique  diameter  of  the  pelvis.  Descent 
and  extension  occur,  and  the  cervico-bregmatic  diameter  becomes 
the    engaging    diameter.     The  head   continues    to    descend  with 


Fig.  215. — The  Mechanism  of  First  Face  Presentation. 
The  head  after  internal  rotation  has  occurred,  as  felt  by  vaginal  examination. 

the  chin  lying  lowest,  until  the  pelvic  floor  is  reached,  when 
internal  rotation  occurs,  and  the  chin,  which  up  to  this  lay  at  the 
posterior  end  of  the  left  oblique  diameter,  rotates  through  three- 
eighths  of  a  circle,  and  comes  to  lie  under  the  symphysis.  The 
shoulders,  which  first  lay  in  the  right  oblique  diameter,  follow  part 
of  this  movement,  and  come  to  lie  in  the  left  oblique  diameter. 
Flexion  occurs  as  before,  the  head  is  born,  and  restitution  follows. 
Finally,  the  anterior  shoulder  rotates  in  front,  and  the  accompany- 
ing external  rotation  proper  carries  the  chin  back  again  to  point 
to  the  left  thigh  of  the  mother. 

In  the  second  position,  with  the  back  behind — third  position  of 
Naegele,  left  mento-anterior — the  head  enters  the  brim  with  a 
diameter  between  the  mento-occipital  and  cervico-bregmatic 
diameters,  corresponding  to  the  right  oblique  diameter  of  the 
pelvis.     Descent  and  extension  occur,  and  the  cervico-bregmatic 


ABNORMAL  MECHANISM  IN  FACE  PRESENTATION         377 

diameter  becomes  the  engaging  diameter.  Internal  rotation 
occurs  through  one-eighth  of  a  circle,  and  brings  the  chin  from 
the  anterior  end  of  the  right  oblique  diameter  to  lie  under  the 
symphysis.  Flexion  occurs  as  before,  the  head  is  born,  and 
restitution  follows.  Finally,  the  anterior  shoulder  rotates  in  front, 
and  the  accompanying  external  rotation  proper  carries  the  chin 
back  again  to  point  towards  the  left  thigh  of  the  mother. 

A  bnovmalities    of    Mechanism    in    Face   Presentation.  —  The    only 


Fig.  216. — Reversed  Rotation  of  the  Head. 

The  head  after  internal  rotation  has  occurred,  and  the  chin  rotated  into  the 
hollow  of  the  sacrum. 

abnormality  in  the  mechanism  of  a  face  presentation  which  is  of 
practical  importance  is  that  of  reversed  rotation  of  the  head,  in 
which  the  chin  rotates  into  the  hollow  of  the  sacrum. 

Reversed  Rotation  of  the  Head. — Just  as  in  a  vertex  presentation 
the  occiput  may  rotate  into  the  hollow  of  the  sacrum  instead  of 
rotating  anteriorly,  so  in  a  face  presentation  the  chin  may  rotate 
in  the  same  direction  (v.  Fig.  216).  The  analogy,  however,  here 
stops,  for  whereas  in  posterior  rotation  of  the  occiput  delivery  most 
usually  occurs   spontaneously,  in  posterior  rotation  of  the  chin 


378 


THE  PHYSIOLOGY  OF  LABOUR 


delivery  by  any  means  short  of  craniotomy  is  usually  impossible. 
The  reason  of  this  is  very  clear.  As  we  have  already  explained 
when  discussing  the  mechanism  of  a  vertex  presentation,  the  par- 
turient canal  is  in  the  form  of  a  curve,  with  the  concavity  forwards, 
and  if  the  foetus  is  to  traverse  this  canal,  it  must  be  capable 
of  accommodating  itself  to  this  curve.  In  the  case  of  a  vertex 
presentation,  this  accommodation  occurs  during  the  final  act  of 
extension  of  the  head,  and  in  the  normal  mechanism  of  a  face 
presentation  it  occurs  during  flexion.  But,  in  the  case  of  a  face 
presentation  with  the  chin  behind,  accommodation  cannot  take 
place,  as,  in  order  that  it  may  do  so,  the  head  must  extend,  and 
extension  has  already  occurred  to  the  utmost  possible  degree. 
Further,   the  occiput,  is  lodged  behind  the  symphysis   in   such 


Fig.  217. — Reversed  Rotation  of  the  Head. 
The  face  as  felt  by  vaginal  examination. 


a  manner  that,  even  if  the  neck  permitted  of  additional  extension, 
the  latter  could  not  occur.  Another  way  of  explaining  the 
impaction  which  occurs  in  these  cases  is  as  follows  : — The  occiput 
cannot  escape  from  behind  the  symphysis,  consequently,  if  the 
head  is  to  be  born,  the  chin  must  move  forward  over  the  perinseum 
until  it  clears  the  latter.  The  neck  is,  however,  not  long  enough 
to  allow  this  to  take  place  unless  the  foetal  trunk  descends 
further  into  the  pelvis  ;  and  this  descent  is  impossible,  as  there  is 
no  room  for  both  the  occiput  and  the  chest  of  the  foetus  at  the 
same  level  in  the  pelvis  (v.  Fig.  216).  Accordingly,  if  this  devia- 
tion from  the  normal  mechanism  occurs,  the  further  delivery  of 
the  foetus  is  impossible,  save  perhaps  in  the  case  of  a  very  large 
pelvis  and  of  a  small  or  macerated  fectal  head. 


THE  MANAGEMENT  OF  FACE  PRESENTATION  379 

Moulding. — The  moulding  of  the  head  in  face  presentation  is 
usually  considerable,  and  is  very  characteristic.  As  a  result  of 
the  pressure  of  the  pelvis,  the  vault  of  the  head  is  flattened,  while 
the  forehead  and  the  occiput  become  more  prominent.  In  con- 
sequence, there  is  a  diminution  in  the  length  of  the  cervico- 
bregmatic,  cervico-frontal,  sub-occipito-bregmatic,  supra-occipito- 
mental,  bi-temporal,  and  bi-parietal  diameters,  and  a  compensatory 
increase  in  the  length  of  the  occipito-frontal  and  occipito-mental 
diameters  (v.  Fig.  218).  The  caput  succedaneum  is  also  usually 
well  marked  in  consequence  of  the  soft  and  yielding  nature  of  the 
tissues  of  the  face.  It  usually  forms  about  the  lower  portion  of 
the  cheek  and  the  angle  of  the  mouth,  and  on  the  right  or  left  side, 
according  as  the  foetus  lay  in  the  first  or  second  position.  If  the 
chin  rotates  posteriorly,  the  caput  forms  over  the  eyes  and  fore- 


m  v j 

c 


Fig.  218. — The  Moulding  of  the  Head  in  Face  Presentation. 
The  black  outline  shows  the  unmoulded,  the  red  the  moulded  head.    (Budin.) 

head.  In  some  cases  extreme  temporary  deformity  and  disfigure- 
ment may  occur,  the  eyelids  and  lips  becoming  enormously 
swollen.  Sub-conjunctival  haemorrhages  are  also  met  with,  and 
ecchymosis  of  the  skin.  To  such  an  extent  may  the  latter  occur, 
that  the  face  may  be  quite  black.  Mauriceau  relates  an  instance 
of  such  a  case,  in  which  the  mother  attributed  the  appearance  of 
the  child  to  the  impression  produced  by  the  sight  of  a  negro  a 
short  time  previous  to  delivery.  Traces  of  the  changes  produced 
by  moulding  frequently  persist  during  life,  but  the  disfigurement 
produced  by  the  caput  succedaneum  passes  off  in  a  few  days. 

Management. — We  have  seen  from  the  foregoing  account  of  the 
mechanism  of  labour  that,  in  the  majority  of  cases,  when  the 
normal  mechanism  occurs,  there  is  nothing  to  prevent  the  foetus 
from  being  delivered  spontaneously.  On  the  other  hand,  we 
have  also  seen  that  delivery  is  slow,  and  that  in  rare  cases  the 


38o 


THE  PHYSIOLOGY  OF  LABOUR 


chin  may  rotate  posteriorly,  and  the  further  progress  of  the  case 
be  prevented.  Accordingly,  the  first  point  in  discussing  the 
management  of  face  presentations  is  to  decide  the  question,  Is  it 


Fig.  219. — Schatz'  Method  of  converting  a  Face  Presentation  into 
a  Vertex  :   the  First  Step. 

The  arrows  show  the  direction  in  which  the  hands  move. 


THE  MANAGEMENT  OF  FACE  PRESENTATION 


38i 


necessary  to  change  every  face  presentation  into  a  vertex,  or  may 
it  be  allowed  to  persist  ?  In  order  to  answer  this  question,  we 
must  first  ascertain  the  various  methods  by  which  a  face  can  be 
turned  into  a  vertex,  or,  in  other  words,  by  which  full  flexion  of 
the  head  can  be  obtained. 


Fig.  220. — Schatz'  Method  of  converting  a  Face  Presentation  into 
a  Vertex  :   the  Second  Step. 

The  arrows  show  the  directions  in  which  the  shoulders  and  back  are 
respectively  pushed. 


382  THE  PHYSIOLOGY  OF  LABOUR 

Flexion  by  External  Manipulations. — The  method  of  converting 
a  face  presentation  into  a  vertex  by  external  manipulations  alone 
•was  introduced  by  Schatz*  in  1873,  and  has  since  been  known  by 
his  name.  In  order  to  perform  it  successfully,  the  face  must 
be  free  above  the  brim,  the  membranes  unruptured,  and  the 
abdominal  wall  lax.  Unfortunately,  it  is  usually  impossible  to 
obtain  the  first  two  of  these  conditions,  as  it  often  happens  that 


Fig.  221. — Schatz'  Method  of  converting  a  Face  Presentation  into 
a  Vertex  :  the  Final  Step. 

the  existence  of  a  face  presentation  is  not  discovered  until  the 
head  is  fixed,  and  perhaps  the  membranes  ruptured  as  well.  The 
necessary  laxity  of  the  abdominal  wall  can  always  be  obtained  by 
the  administration  of  an  anaesthetic.  The  patient  lies  on  the  back 
as  if  for  the  performance  of  abdominal  palpation,  and  the  operator 
ascertains  by  careful  palpation  the  position  of  the  foetus.  Then, 
in  the  interval  between  two  uterine  contractions,  he  grasps  the 
anterior   shoulder  with  one  hand   and   the  back  just  below  the 

*  Archiv  f.  Gynak.,  V.,  306 


THE  MANAGEMENT  OF  FACE  PRESENTATION 


38- 


breech  with  the  other,  and  endeavours  to  draw  the  foetus  towards 
the  fundus  (v.  Fig.  219).  This  procedure  straightens  the  foetus, 
and  brings  the  head  into  a  position  between  extension  and  flexion. 
The  hand  on  the  anterior  shoulder  then  presses  the  latter  in  the 
direction  of  the  back  of  the  foetus,  while  the  other  hand  presses 
the  breech  in   the  opposite  direction,  and  so  produces  a  flexed 


Fig.  222. — Baudelocque's  Method  of  converting  a  Face  Presentation 
into  a  Vertex  :   the  First  Step. 

The  fingers  of  the  left  hand  in  the  cervix  push  the  lower  jaw  upwards,  while 
the  other  hand  on  the  abdominal  wall  pushes  the  occiput  downwards. 

position  of  the  head  (v.  Fig.  220).  Finally,  the  hand  on  the 
breech  presses  straight  downwards,  and  so  drives  the  vertex 
into  the  brim  (v.  Fig.  221).  The  head  must  be  kept  in  this 
position  with  the  hand,  or  by  the  application  of  a  tight  binder, 
until  it  fixes,  or  else  the  face  presentation  may  recur.     If  the 


384 


THE  PHYSIOLOGY  OF  LABOUR 


uterine  orifice  is  fairly  well  dilated,  the  rupture  of  the  membranes 
will  hasten  fixation. 

Flexion  by  Combined  External  and  Internal  Manipulations. — 
There  are  two  methods  by  which  flexion  of  the  head  can  be 
obtained  by  combined  manipulations,  provided  that  the  head  is 
not  too  deeply  fixed  in  the  pelvis. 


Fig.  223. 


-Baudelocque's  Method  of  converting  a  Face  Presentation 
into  a  Vertex  :  the  Second  Step. 


The  ringers  of  the  left  hand  push  the  forehead  upwards,  the  outer  hand 
continuing  to  push  the  occiput  downwards. 


(1)  Baudelocque's  Method.* — For  the  performance  of  this  method, 

the  uterine  orifice  must  be  sufficiently  dilated  to  admit  two  fingers, 

and  the  patient  must,  if  possible,  be  under  an  anaesthetic.     She 

is    placed   in    the    cross-bed   position,    and   the  operator   passes 

*   '  L'Art  des  Accouchements,'  1789,  vol.  ii  ,  pp.  36-40. 


THE  MANAGEMENT  OF  FACE  PRESENTATION 


3*5 


into  the  vagina  the  hand  corresponding  to  the  side  at  which  the 
chin  lies.  Then,  passing  two  fingers  into  the  uterus,  he  applies 
upward  pressure  first  upon  the  lower  jaw  (v.  Fig.  222),  then  upon 
the  upper  jaw,  and  lastly  on  the  forehead,  while  at  the  same  time 
he  presses  down  the  occiput  from  without  with  the  other  hand 
(v.    Fig.  223).     If  the  uterine  orifice  is  sufficiently  dilated,   the 


¥* 


Fig.  224. — The  Playfair-Partridge  Method  of  converting  a  Face 
Presentation  into  a  Vertex. 

The  right  hand  on  the  uterus  draws  the  occiput  downwards,  while  the  left 
hand  on  the  abdominal  wall  pushes  the  shoulder  in  the  direction  of  the 
back. 


whole  hand  may  be  passed  into  the  uterus,  and  the  face  grasped 
and  pushed  upwards  out  of  the  brim  before  endeavouring  to 
obtain  flexion.  This  procedure  is  especially  necessary  in  cases 
where  the  face  is  fixed.  The  performance  of  Baudelocque's 
method  may  be   facilitated  by  the  adoption  of  an  expedient  in- 

25 


386  THE  PHYSIOLOGY  OF  LABOUR 

troduced  by  Ziegenspeck,*  by  which  an  assistant  presses  the 
shoulders  in  the  direction  of  the  child's  back  and  the  breech  in 
the  opposite  direction,  as  in  Schatz'  method,  while  at  the  same 
time  the  operator  carries  out  the  procedure  just  described. 

(2)  The  Play  fair- Partridge  Method,  f — For  the  performance  of  this 
method  the  uterine  orifice  must  be  sufficiently  dilated  to  admit 
the  hand,  and  the  patient,  as  before,  must  be  under  an  anaesthetic. 
The  patient  is  placed  in  the  dorsal  position  and  the  operator 
introduces  into  the  vagina  the  hand  corresponding  to  the  side 
towards  which  the  occiput  is  turned.  Then,  passing  the  hand 
into  the  uterus  and  above  the  occiput,  h£  grasps  the  latter  and 
draws  it  downwards,  while  with  the  external  hand  he  pushes  the 
chest  of  the  foetus  upwards  and  in  the  direction  of  the  back 
(v.  Fig.  224). 

A  few  words  of  warning  must  be  given  regarding  the  perform- 
ance of  either  of  the  foregoing  methods.  In  every  case  particular 
attention  must  be  directed  to  ensuring  that,  whatever  method  is 
adopted,  flexion  is  complete,  and  that  the  anterior  fontanelle  lies 
at  a  higher  level  than  the  posterior.  There  is  always  a  risk  in 
these  cases  that  the  pre-existing  face  presentation  may  be  con- 
verted into  a  brow  presentation,  and,  as  we  shall  see  presently, 
this  would  be  a  most  unfortunate  occurrence  and  one  which  would 
make  the  prognosis  of  the  case  considerably  worse. 

Podalic  Version.— There  is  another  line  of  treatment  in  a  face 
presentation  which  must  also  be  considered.  A  face  presentation 
may  be  turned  into  a  pelvic  presentation  by  performing  the  opera- 
tion known  as  version.  A  pelvic  presentation  is  more  dangerous 
for  the  infant  than  is  a  vertex,  but  it  is  considerably  less  dangerous 
for  both  mother  and  infant  than  is  a  face,  and,  accordingly,  under 
certain  circumstances  it  may  be  advisable  to  perform  version  in 
face  presentation. 

We  must  now  decide  on  what  we  consider  the  most  suitable 
treatment  to  adopt  in  cases  of  face  presentation.  If  the  case  is 
seen  in  sufficient  time  to  perform  Schatz'  method,  there  is  no 
doubt  that  it  should  be  attempted.  If  it  fails  and  if  the  chin  is 
directed  anteriorly  the  presentation  may  be  left  unchanged,  as  it 
will  almost  certainly  be  delivered  spontaneously.  If,  on  the  other 
hand,  the  chin  is  directed  posteriorly,  either  Baudelocque's  or  Part- 
ridge's method  should  be  adopted,  and  a  vertex  presentation  sub- 
stituted for  the  face.  If  they  fail,  or  if,  after  having  procured 
a  vertex  presentation,  the  face  presentation  recurs,  we  may  turn 
the  fcetus  by  external  version.  If,  on  the  other  hand — as  usually 
is  the  case — the  face  is  fixed  in  the  brim  before  its  nature  is 
recognised,  the  presentation  may  be  allowed  to  persist,  and  in  all 
probability  delivery  will  occur  spontaneously. 

If  the  presentation  is  allowed  to  persist  the  important  points  in 

*  '  Beitrage  zur  Behandlung  der  Gesichtslagen.' 

t  New  York  Med.  Journ.,  March,  1887,  and  Amer.  Journ.  of  Obstet.,  1884, 
P-  593- 


1JR0W  PRESENTATION  387 

the  conduct  of  the  case  are  as  follows  : — The  patient  should  be 
kept  in  bed  during  the  latter  half  of  the  first  stage,  especially  if 
the  membranes  are  bulging  unduly  through  the  os  externum,  in 
order  to  avoid  their  rupture.  During  the  second  stage,  she  should 
lie  on  the  side  to  which  the  chin  is  turned,  as  this  favours  its 
anterior  rotation.  As  the  head  approaches  the  perinaeum  a 
vaginal  examination  must  be  made,  to  determine  whether  anterior 
rotation  of  the  chin  is  occurring.  If  it  is  not  doing  so,  an  attempt 
should  be  made  to  convert  the  face  into  a  vertex  by  Baudelocque's 
or  Partridge's  method,  or,  if  they  fail,  anterior  rotation  may  be 
assisted  by  pressing  the  forehead  upwards  with  the  fingers  in 
the  vagina  during  several  contractions,  as  this  retards  the  descent 
of  that  part,  and,  by  causing  the  chin  to  become  lowest,  favours 
its  anterior  rotation.  If  rotation  still  does  not  occur,  or  if  posterior 
rotation  of  the  chin  occurs,  place  the  patient  under  an  anaesthetic, 
and,  introducing  the  hand  into  the  vagina,  grasp  the  face  and 
endeavour  to  rotate  it  so  as  to  bring  the  chin  forward  by  the 
shortest  route.  This  procedure  may  be  assisted  by  at  the  same 
time  pressing  the  anterior  shoulder  to  the  front  with  the  hand 
upon  the  abdomen.  If  this  fails  the  forceps  may  be  tried,  pro- 
vided that  the  chin  has  not  rotated  into  the  hollow  of  the  sacrum. 
If  the  forceps  fails,  or  if  the  chin  had  already  rotated  posteriorly, 
the  head  must  be  perforated. 

Prognosis. — The  prognosis  in  face  presentation  is  more  serious 
for  both  the  mother  and  the  fcetus.  In  the  case  of  the  mother 
this  is  accounted  for  by  the  long  duration  of  labour  and  by  the 
internal  manipulations  which  are  usually  necessary.  In  the  case 
of  the  foetus  the  mortality  has  been  estimated  at  13  per  cent,  by 
some,  by  others  (Galabin)  at  8*4  per  cent.  This  is  due  in  part  to 
the  long  labour,  and  in  part  to  the  stretching  and  compression  of 
the  neck  which  results  from  the  over-extension  of  the  head. 

In  all  cases,  the  friends  of  the  patient  must  be  warned  before- 
hand that  labour  will  be  tedious,  and  that  in  all  probability  there 
will  be  considerable  temporary  disfigurement  of  the  fcetus. 


BROW  PRESENTATION 

A  brow  presentation  is  the  term  applied  to  the  presentation 
when  the  sinciput,  or  region  of  the  head  between  the  supra-orbital 
ridges  and  the  anterior  fontanelle,  lies  lowest  (v.  Fig.  225). 

Frequency. — It  is  difficult  to  obtain  any  reliable  figures  to  show 
the  relative  frequency  of  brow  presentations.  Some  authors  do 
not  consider  a  brow  presentation  as  a  separate  presentation,  but 
term  it  a  variety  of  face  presentation,  while  others  include  in  their 
figures  all  cases  in  which  a  brow  presentation  was  recognised  at 
any  period  of  labour,  and  so,  doubtless,  include  many  cases  of 
face  presentation,  as  a  brow  presentation  is  of  necessity  a  stage 
in  every  case  of  secondary  face  presentation.     Perhaps,  in  com- 

25—2 


388  THE  PHYSIOLOGY  OF  LABOUR 

piling  statistics,  it  would  be  best  to  include  only  those  cases  in 
which  a  brow  presentation  is  recognised  and  changed,  or  passes 
through  the  brim  as  a  brow  presentation.  The  proportion  of 
cases  of  brow  presentation,  estimating  on  this  basis,  is  said  to  be 
about  i  in  500.  At  the  Rotunda  Hospital,  amongst  19,293  cases, 
brow  presentation    occurred    30   times,   or  a  proportion  of   1  in 


Fig.  225. — First  Brow  Presentation. 

643*1.  These  figures  contrast  markedly  with  those  of  Guy's 
Hospital,  where  brow  presentation  was  only  observed  30  times 
amongst  49,145  deliveries,*  or  a  proportion  of  1  in  1,638.  This 
is  the  more  strange  as  apparently  five  sixths  of  these  were  cases 

*  Galabin,  'Manual  of  Midwifery,'  fifth  edition,  p.  238. 


THE  CAUSES  OF  BROW  PRESENTATION 


3S9 


which  converted  themselves  into  face  presentations,   and  such 
cases  are  not  included  in  the  Rotunda  figures. 

Aetiology. — A  brow  presentation  is  a  stage  between  a  face 
presentation  and  a  vertex  presentation.  As  is  to  be  expected, 
the  natural  effect  of  the  contractions  of  the  uterus  and  of  the 
resistance  of  the  pelvic  brim  is  to  bring  the  head  into  a  position 
of  stable  equilibrium  either  by  causing  full  flexion  and  bringing 
the  chin  into  apposition  with  the  chest,  or  full  extension  and 
bringing  the  occiput  into  contact  with  the  back.  When  a  brow 
presentation  occurs,  the  head  is  in  a  position  of  unstable  equi- 
librium, midway  between  flexion  and  extension,  and  can  only 
remain  in  this  position  so  long  as  the  forces  to  which  it  is  sub- 


Fig.   226. — First  Brow  Presentation. 
The  head  presenting  at  the  brim,  as  felt  by  vaginal  examination. 

jected  are  equally  distributed  over  its  surface.  Once  the  resist- 
ance offered  to  the  descent  of  the  occiput  and  vertex  becomes 
greater  than  that  offered  to  the  face,  extension  occurs  and  a  face 
presentation  results,  while,  if  the  contrary  happens,  flexion  occurs 
and  a  vertex  presentation  results.  We  may  then  consider  as 
causes  of  a  brow  presentation  the  association  of  any  factors  which 
cause  partial  extension  of  the  head  with  such  a  mutual  adaptation 
between  the  shape  and  position  of  the  head  and  the  shape  of  the 
pelvis  as  will  enable  the  head  to  maintain  its  position  of  unstable 
equilibrium  between  flexion  and  extension.  The  various  factors 
which  may  produce  partial  extension  are  the  same  as  those  which 
may  produce  complete  extension,  and  as  they  have  been  referred  to 
when  discussing  the  aetiology  of  face  presentation  they  need  not 
be  again  enumerated. 


39° 


THE  PHYSIOLOGY  OF  LABOUR 


Positions. — The  foetus  can  lie  in  one  of  two  positions,  according 
as  the  back  is  directed  to  the  left  or  to  the  right.  It  is  probable 
that,  on  account  of  the  length  of  the  engaging  diameter  of  the 
head  in  this  presentation,  in  all  cases  in  which  the  head  engages 
in  the  brim  it  does  so  with  its  supra-occipito-mental  diameter  in  the 
transverse  diameter  of  the  brim.  Accordingly,  it  is  unnecessary 
to  sub-divide  each  position  according  as  the  back  is  in  front  or 
behind,  as  is  done  in  the  case  of  the  other  presentations.  The 
positions  may,  therefore,  be  tabulated  as  follows  : — 

First  position,  back  to  the  left. 

Second  position,  back  to  the  right. 

In  all  probability  the  first  position  is  the  more  common. 


Fig.  227. — Second  Brow  Presentation. 
The  head  presenting  at  the  brim,  as  felt  by  vaginal  examination. 


Diagnosis. — The  diagnosis  of  brow  presentation  can  be  made  by 
abdominal  palpation  and  by  vaginal  examination  ;  the  assistance 
rendered  by  auscultation  is  but  slight. 

Abdominal  Palpation. — The  pelvic  pole  of  the  foetus  is  found  at 
the  fundus.  The  lie  is  longitudinal,  with  the  back  directed  to  one 
or  other  side  according  to  the  position.  The  head  occupies  the 
lower  segment  of  the  uterus,  and  usually  lies  high  above  the  brim, 
as  the  length  of  its  engaging  diameter  obstructs  its  descent. 
The  occipital  tumour  is  more  prominent  than  in  a  vertex  presenta- 
tion, but  not  so  prominent  as  in  a  face  presentation.  It  lies  at  the 
same  level  as  does  the  chin,  and  the  groove  of  the  neck  runs 
transversely  across  the  uterus. 

Vaginal  Examination. — At   the  commencement  of   labour  the 


THE  DIAGNOSIS  OF  BROW  PRESENTATION 


391 


head  lies  so  high  above  the  brim  that  it  is  difficult  to  reach  the 
presenting  part,  and  to  enable  us  to  do  so  the  greater  part  of  the 
hand  must  be  passed  into  the  vagina.  The  diagnosis  of  a  brow 
is  made  by  finding  at  one  side  of  the  pelvis  the  frontal  bone,  whose 
smooth  and  rounded  surface  resembles  the  contour  of  the  vertex 
and  is  intersected  by  a  suture,  and  on  the  other  side  the  irregular 


Fig.  228. — The  Mechanism  of  First  Brow  Presentation. 
The  head  presenting  at  the  brim. 

outline  of  the  supra-orbital  ridges  and  the  malar  bones.  If  the 
membranes  are  intact  they  bulge  through  the  uterine  orifice, 
owing  to  the  lack  of  accommodation  between  the  head  and  the 
lower  uterine  segment.  The  position  in  which  the  fetus  lies 
can  be  determined  by  noting  the  side  of  the  pelvis  at  which  the 
anterior  fontanelle  lies. 


392  THE  PHYSIOLOGY  OF  LABOUR 

Auscultation. — The  foetal  heart  will  probably  be  heard  with 
difficulty,  owing  to  the  fact  that  the  foetal  body  lies  more  centrally 
in  the  uterus  than  in  the  other  presentations.  It  will  be  heard 
best  to  the  left  or  the  right  of  the  middle  line,  according  as  the 
foetus  lies  in  a  first  or  a  second  position. 

Mechanism. — When  the  brow  presents  at  the  pelvic  brim,  the 
greatest  engaging  diameters  of  the  head  are  the  supra-occipito- 
mental  and  the  bi-parietal.  The  supra-occipito-mental  diameter 
is,  however,  ^\  inches  in  length,  while  the  length  of  the  greatest 
diameter  of  the  pelvis — i.e.,  the  transverse — is  only  5^  inches ; 
consequently,  in  the  case  of  a  normally-sized  foetus  and  a 
normally-sized  pelvis,  the  mechanism  of  labour  in  a  brow  pre- 
sentation  commences  and  ends  by  the  foetal  head  being  driven 


Fjg.  229. — The  Moulding  of  the  Head  in  Brow  Presentation. 

The  black  outline  represents  the  unmoulded,  the  red  the  moulded  head. 

(Budin.) 

into  the  brim  and  remaining  there.  If,  however,  the  foetus  is 
small  or  macerated,  or  the  pelvis  very  roomy,  the  head  may  be 
squeezed  past  the  brim,  after  a  considerable  degree  of  moulding 
has  taken  place,  with  the  supra-occipito-mental  diameter  corre- 
sponding to  the  transverse  diameter  of  the  pelvis.  Four  termina- 
tions of  the  case  are  then  possible  : — 

(1)  The  brow  presentation  may  persist  and  the  head  be  expelled 
as  such. 

(2)  The  brow  presentation  may  be  changed  iDto  a  face  presenta- 
tion as  the  head  passes  through  the  pelvis. 

(3)  The  brow  presentation  may  be  changed  into  a  vertex  pre- 
sentation. 

(4)  The  head  may  become  impacted  in  the  pelvis. 

If  the  brow  presentation  persists,  internal  rotation  takes  place 
in    the   usual    manner,    and    brings   the   upper  jaw   behind   the 


THE  MANAGEMENT  OF  BROW  PRESENTATION  393 

symphysis,  and  then  the  head,  rotating  round  the  fixed  point  of 
the  jaw,  is  born  by  a  movement  of  flexion.  Restitution  and  the 
expulsion  of  the  trunk  follow  in  the  usual  manner.  Sometimes, 
posterior  rotation  of  the  face  may  occur,  but  this  so  increases  the 
already  considerable  difficulties  of  the  case  that  the  further  ex- 
pulsion of  the  foetus  is  almost  an  impossibility. 

Moulding. — The  moulding  of  the  head  in  cases  which  have  been 
born  as  a  brow  presentation  is  extensive  and  characteristic.  The 
main  alteration  is  considerable  flattening  of  the  vertex,  as  a  result 
of  which  the  supra-occipito-mental  and  bi-parietal  diameters  are 
diminished,  while  there  is  a  compensatory  increase  of  the  occipito- 
frontal, occipito-mental,  and  the  sub-occipito-frontal  diameters 
[v.  Fig.  229).  The  caput  succedaneum  forms  over  the  prominence 
of  the  forehead,  and  is  of  considerable  size. 

Management. — We  have  seen  from  the  foregoing  short  account 
of  the  mechanism  of  labour  in  this  presentation  that  it  may  be 
regarded  as  impossible  for  a  full-sized  foetus  to  pass  through  a 
normally-sized  pelvis  with  the  brow  presenting.  We  have  also 
seen  that,  if  in  the  case  of  a  small  foetus  the  head  does  pass  through 
the  brim,  the  presentation  may  become  altered  in  the  pelvic 
cavity  into  either  a  face  or  a  vertex.  Accordingly,  we  have  got 
a  very  clear  indication  of  what  the  treatment  of  the  presentation 
ought  to  be.  If  a  brow  presentation  is  found  at  the  pelvic  brim, 
it  must  under  no  circumstances  be  allowed  to  persist.  It  is 
always  possible  to  alter  it  when  in  this  position,  unless  labour 
has  advanced  so  far  that  rupture  of  the  uterus  is  feared,  and  in 
such  cases  perforation  must  be  performed.  If  the  head  has  passed 
into  the  pelvic  cavity,  we  must  also  endeavour  to  correct  the 
presentation.  But  if  we  fail  to  do  so,  we  need  not  give  up  all 
hope  of  saving  the  foetus,  as  the  head  may  be  expelled  by  the 
natural  efforts.  In  such  cases  the  patient  should  lie  on  the  side 
to  which  the  face  is  turned,  as  this  favours  its  anterior  rotation. 
If  the  head  still  does  not  advance,  and  the  indications  of  unduly 
prolonged  labour  appear,  we  may  attempt  to  deliver  the  foetus 
with  the  forceps.  Occasionally,  the  foetus  may  be  extracted  in 
this  way,  but  perhaps  more  usually  the  forceps  will  fail  to  effect 
delivery,  and  perforation  will  be  necessary.  As  a  rule,  the  foetus 
will  be  afforded  the  best  chance  of  life  by  leaving  delivery  to  the 
natural  efforts  for  as  long  as  possible.  The  forceps  tends  to 
impact  the  head  in  the  pelvis,  and  to  prevent  the  spontaneous 
correction  of  the  presentation  which  might  have  otherwise 
occurred.  Its  application  should  therefore  be  postponed  for  as 
long  as  possible,  and  then  only  resorted  to  as  a  last  chance  prior 
to  perforation. 

A  brow  presentation  may  be  converted  into  either  a  face  or  a 
vertex,  according  as  complete  extension  or  complete  flexion  of  the 
head  is  brought  about.  If  we  decide  on  attempting  to  bring  about 
a  vertex  presentation,  our  procedure  is  identical  with  that  which 
has  been  recommended  in  the  case  of  a  face  presentation.     If  the 


394  THE  PHYSIOLOGY  OF  LABOUR 

head  is  free  above  the  brim  and  the  membranes  intact,  Schatz' 
method  may  be  tried  (v.  Figs.  219-221),  and  if  this  is  unsuccess- 
ful or  impossible,  Baudelocque's  or  the  Playfair-Partridge  method 
should  be  attempted  (v.  Figs.  222,  223).  If  the  head  has  descended 
too  deeply  into  the  pelvis  to  allow  a  vertex  presentation  to  be 
produced,  an  attempt  may  be  made  to  produce  a  face  presentation. 
To  do  this,  we  press  upwards  at  each  side  of  the  large  fontanelle, 
during  a  contraction,  with  the  fingers  in  the  vagina,  while  at  the 
same  time  the  other  hand  on  the  abdominal  wall  endeavours  to 
press  the  chin  downwards.  This  procedure  is  but  rarely  success- 
ful, but  inasmuch  as  it  does  no  harm,  and  as  it  may  succeed,  it 
is  permissible  to  try  it. 

If  the  head  is  free  above  the  brim,  but  it  is  impossible  to. obtain 
or  to  maintain  a  vertex  presentation,  podalic  version  should  be 
performed  and  a  pelvic  presentation  obtained. 

Prognosis. — The  prognosis  in  a  brow  presentation  is  bad  for  the 
fcetus  and  more  serious  for  the  mother  than  in  either  face  or 
vertex  presentation,  a  fact  which  is  readily  accounted  for  by  the 
prolonged  labour  and  the  amount  of  manipulation  which  is  usually 
necessary.  .     .:..  ,; 


ANTERIOR  FONTANELLE  PRESENTATION 

An  anterior  fontanelle  presentation  is  the  term  applied  to  the 
presentation  when  the  head  lies  in  a  position  midway  between  a 
vertex  presentation  and  a  brow  presentation  and  the  anterior 
fontanelle  lies  lowest  (v.  Fig.  230). 

/Etiology. — There  are  two  very  different  causes  of  anterior 
fontanelle  presentation  ;  the  first  of  these  is  an  unduly  large 
pelvis,  and  the  second  a  flattened  pelvis.  The  former  tends  to 
cause  an  anterior  fontanelle  presentation  owing  to  the  slight 
resistance  it  offers  to  the  descent  of  the  foetal  head.  As  we  have 
already  mentioned,  the  degree  of  flexion  of  the  head  which  occurs 
is  an  index  of  the  amount  of  resistance  which  is  offered  to  the 
head  in  its  passage  through  the  pelvis.  In  a  normal  case,  this 
resistance  is  sufficient  to  produce  a  vertex  presentation,  which 
alters  to  a  presentation  of  the  posterior  fontanelle  as  the  head 
passes  through  the  pelvic  cavity.  In  the  case  of  a  generally 
contracted  pelvis,  as  we  shall  see  in  a  short  time,  the  resistance  is 
sufficient  to  produce  a  presentation  of  the  posterior  fontanelle 
even  while  the  head  is  at  the  brim,  or  in  some  cases  a  presentation 
of  the  occipital  bone.  Accordingly,  it  is  not  strange  that  if  the 
resistance  to  the  descent  of  the  head  is  slight,  the  head  may  pass 
through  the  brim  in  an  insufficiently  flexed  position — i.e.,  as  an 
anterior  fontanelle  presentation.  The  manner  in  which  this 
presentation  is  produced  in  a  flattened  pelvis  is  very  different. 
Owing  to  the  shortening  of  the  oblique  and  conjugate  diameters, 
the  head  engages  in  the  pelvis  with  its  antero-posterior  diameters 


ANTERIOR  FONTANELLE  PRESENTATION 


395 


corresponding  to  the  transverse  diameters  of  the  brim.  Then,  as 
a  result  of  the  greater  resistance  which  is  offered  to  the  passage 
through  the  brim  of  the  bi-parietal  diameter  than  of  the  bi- 
temporal diameter,  the  sinciput  descends  more  rapidly  than  the 
vertex,  and  the  anterior  fontanelle  becomes  the  presenting  point. 
It  must  also  be  mentioned  that  presentation  of  the  anterior 
fontanelle  may  occur  when  the  head  is  deep  in  the  pelvic  cavity. 
Such  cases  are  associated  with  a  posterior  rotation  of  the  occiput 
in  a  vertex  presentation,  and  cannot  strictly  be  included  under  the 
head  of  anterior  fontanelle  presentations. 


Fig.  230. — First  Anterior  Fontanelle  Presentation. 
The  head  presenting  at  the  brim,  as  felt  by  vaginal  examination. 

Positions. — Two  positions  are  met  with  : — 

First  position,  back  to  the  left. 
Second  position,  back  to  the  right. 

Diagnosis. — The  difference  between  the  position  of  the  head  ot 
the  foetus  in  this  position  and  in  vertex  presentation  is  not 
sufficiently  marked  to  enable  the  nature  of  the  case  to  be 
diagnosed  by  abdominal  palpation,  nor  will  auscultation  give 
any  definite  information.  We  therefore  rely  entirely  upon  vaginal 
examination.  By  this  means,  we  find  the  head  presenting,  and 
the  anterior  fontanelle  lying  lowest  and  almost  in  the  centre  of 
the  pelvic  brim.  In  cases  where  there  is  an  accompanying 
Naegele's  obliquity  of  the  head,  the  fontanelle  will  lie  nearer  the 
promontory  than  the  symphysis. 


396  THE  PHYSIOLOGY  OF  LABOUR 

Mechanism. — In  cases  in  which  the  presentation  is  due  to  the 
existence  of  a  flat  pelvis,  the  head  engages  with  its  occipito- 
frontal diameter  in  the  antero-posterior  diameter  of  the  pelvis. 
In  consequence  of  the  resistance  offered  by  the  narrow  conjugate 
to  the  passage  of  the  bi-parietal  diameter,  the  head  glides  towards 
the  side  at  which  the  occiput  lies,  and  so  a  narrower  diameter 
than  the  bi-parietal  is  brought  into  the  conjugate  diameter. 
At  the  same  time,  a  varying  degree  of  Naegele's  obliquity  is 
produced  (v.  Fig.  187).  The  contractions  of  the  uterus  continuing, 
the  head  is  driven  through  the  brim,  if  the  disproportion  is  not  too 
great.  Then,  as  a  rule,  the  usual  degree  of  flexion  of  the  head 
occurs,  and  the  remainder  of  the  mechanism  is  similar  to  that  of  a 
vertex  presentation. 

In  cases  in  which  the  presentation  is  not  associated  with  con- 
tracted pelvis,  the  head  passes  through  the  brim  in  the  usual 
manner,  save  that  the  anterior  fontanelle  presents.  Then,  on 
reaching  the  pelvic  floor,  in  consequence  of  the  incomplete  flexion 
of  the  head,  the  sinciput  may  rotate  beneath  the  pubis.  In  such 
cases,  the  remainder  of  the  mechanism  is  similar  to  that  of  a 
vertex  in  which  the  occiput  has  rotated  posteriorly. 

Management. — The  presence  of  an  anterior  fontanelle  presentation 
does  not  in  itself  necessitate  any  interference  with  the  course  of 
labour,  as  it  is  but  rarely  that  the  presentation  occurs  save  when 
it  is  suitable,  as  in  flattened  pelves,  or  when  the  pelvis  is  very 
roomy.  As,  however,  it  is  usually  associated  with  a  lack  of 
adaptation  between  the  presenting  head  and  the  lower  uterine 
segment,  and  so  with  a  tendency  to  premature  rupture  of  the 
membranes,  the  patient  should  be  kept  in  bed  during  the  first 
stage.  In  a  case  of  flattened  pelvis,  she  should  at  first  lie  upon 
the  side  towards  which  the  sinciput  is  directed  ;  and  then,  as  soon 
as  the  head  has  passed  the  brim,  upon  the  opposite  side,  in  order 
to  promote  the  descent  of  the  posterior  fontanelle. 

Prognosis. — The  prognosis  of  the  case  for  both  mother  and 
child  depends  on  the  cause  of  the  presentation,  and,  in  the  case 
of  a  flattened  pelvis,  on  the  degree  of  contraction  present. 
If  the  presentation  persists  and  the  occiput  rotates  posteriorly, 
the  prognosis  of  the  case  is  perhaps  slightly  more  unfavourable 
than  in  a  vertex  presentation. 


POSTERIOR  FONTANELLE  PRESENTATION. 

A  posterior  fontanelle  presentation  is  the  term  applied  to  the 
presentation  when  the  head  lies  in  a  fully  flexed  position,  the 
posterior  fontanelle  lying  lowest  (v.  Fig.  231)..  This  condition  is 
also  known  as  Roederer's  obliquity. 

Aetiology. — As  has  been  already  mentioned,  the  degree  of  flexion 
which  occurs  is  in  proportion  to  the  resistance  offered  to  the 
passage  of  the  head  through  the  brim.    Consequently,  presentation 


POSTERIOR  FONTANELLE  PRESENTATION 


397 


of  the  posterior  fontanelle  will  be  expected  when  the  resistance 
to  the  descent  of  the  head  is  greater  than  normal.  This  occurs 
in  a  generally  contracted  pelvis,  or  in  the  case  of  an  unduly  large 
foetal  head.  It  must  also  be  mentioned  that  presentation  of  the 
posterior  fontanelle  occurs  in  the  ordinary  mechanism  of  a  vertex 
presentation  after  the  head  has  passed  through  the  brim,  but  such 
cases  are  classed  as  vertex  presentations. 

Positions.— Two  positions  are  met  with,  according  as  the  back 
lies  on  the  left  or  on  the  right : — 

First  position,  back  to  the  left. 
Second  position,  back  to  the  right. 


Fig.   231. — First  Posterior  Fontanelle  Presentation. 
The  head  presenting  at  the  brim,  as  felt  by  vaginal  examination. 


Diagnosis. — As  in  the  case  of  anterior  fontanelle  presentation, 
the  diagnosis  can  only  be  made  by  vaginal  examination.  By  this 
means  the  head  is  found  presenting,  and  the  posterior  fontanelle 
constituting  the  presenting  point. 

Mechanism. — The  head  first  presents  at  the  brim  with  its 
occipito-frontal  diameter  corresponding  to  the  oblique  diameter 
of  the  pelvis.  As  the  contractions  continue,  flexion  becomes 
more  marked  than  normal  owing  to  the  resistance  offered  to  the 
descent  of  the  sinciput  by  the  pelvic  inlet,  and  the  posterior 
fontanelle  becomes  the  presenting  point,  even  though  the  head 
has  not  yet  entered  the  brim.  In  some  cases,  flexion  may  even 
proceed  so  far  that  the  occipital  bone  lies  lowest,  thus  giving 
rise  to  the  so-called  occipital  presentation.     If  the  head  passes 


398  THE  PHYSIOLOGY  OF  LABOUR 

through  the  brim,  the  remainder  of  the  mechanism  of  the  case 
is  similar  to  that  of  a  vertex  presentation. 

Moulding. — The  occipito-mental  diameter  of  the  head  is  con- 
siderably elongated,  so  that  the  head  presents  the  appearance  of 
having  been  drawn  out.  The  occipito-frontal  and  sub-occipito- 
bregmatic  diameters  are  shortened.  The  caput  succedaneum  is 
formed  round  the  posterior  fontanelle  and  in  part  on  the  occipital 
bone,  and  is  usually  of  large  size. 

Management. — If  the  posterior  fontanelle  is  found  presenting  at 
the  brim,  we  must  endeavour  to  determine  the  cause.  If  the 
pelvis  is  generally  contracted,  the  treatment  proper  to  the  degree 
of  contraction  must  be  adopted.  If  the  degree  is  not  too  great  to 
allow  the  passage  of  the  head,  the  presentation  of  the  posterior 
fontanelle  may  be  encouraged,  as  it  is  most  suitable  in  such  cases. 
To  this  end,  the  patient  lies  on  the  side  towards  which  the  occiput 
is  turned.  If  there  is  no  pelvic  contraction  present,  the  head 
must  be  allowed  to  mould  until  indications  necessitating  the 
delivery  of  the  patient  occur.  Then,  an  attempt  may  be  made 
to  -deliver  by  means  of  the  forceps,  but  if  this  fails  perforation 
will  be  necessary - 

Prognosis.—The  prognosis  depends  upon  the  cause  of  the  con- 
dition, and  in  the  case  of  contracted  pelvis  upon  the  degree  of 
contraction.  The  accurate  manner  in  which  the  head  fits  the 
pelvic  brim  in  cases  of  generally  contracted  pelvis  may  lead,  in 
cases  in  which  labour  is  prolonged,  to  considerable  necrosis  of 
tissue  as  a  result  of  pressure  For  the  same  reason,  there  is 
sometimes  so  marked  pressure  upon  the  ureters  as  to  cause 
obstructive  suppression  of  urine,  and  so  to  favour  the  occurrence 
of  eclampsia. 


CHAPTER  VI 
PELVIC  PRESENTATION 

Complete  Pelvic  Presentations  — Incomplete  Pelvic  Presentations — Frequency 
— ^Etiology — Positions — Diagnosis — Mechanism  —  Abnormal  Mechanism , 
Reversed  Rotation  of  Head — Management — Prognosis. 

The  term  '  pelvic  presentation  '  is  used  to  include  all  presentations 
in  which  the  lower  pole  of  the  fcetus  presents.     In  consequence  of 


Fig.  232. — First  Pelvic  Presentation,  the  Back  in  Front. 

the  different  attitudes  which  the  fcetus  may  assume,  the  following 
divisions  and  subdivisions  of  the  presentation  must  be  made  : — 

399 


400 


THE  PHYSIOLOGY  OF  LA  BON  R 


(i)  Complete  Pelvic  Presentation. — In  this,  the  foetus  preserves 
its  normal  attitude,  and,  consequently,  the  breech  and  feet  are 
found  at  the  brim,  and  pass  through  the  pelvis  together  (v. 
Fig.  232). 

(2)  Incomplete  Pelvic  Presentation.  —  Any  variation  from 
the  normal  attitude  of  the  foetus  will  cause  an  incomplete  pelvic 
presentation.  Thus,  the  legs  may  be  fully  extended  at  both  hip 
and  knee,  and  so  the  feet  present ;  or,  they  may  be  flexed  at  the 
hips,  but  extended  at  the  knees,  and  so  the  breech  alone  present ; 
or  the  reverse  may  happen,  the  thighs  being  extended,  and  the 
lower  legs  flexed,  so  causing  a  knee  presentation  ;  or,  lastly,  any 
combination  of  these  conditions  may  occur,  one  leg,  for  instance, 


Fig.  233. — -First  Pelvic  Presentation,  with  the  Back  in  Front. 
The  breech  presenting  at  the  brim,  as  felt  by  vaginal  examination. 


being  fully  extended,  the  other  fully  flexed,  or  flexed  at  the  hip 
and  extended  at  the  knee.  The  terms  to  be  used  to  describe 
these  variations  of  an  incomplete  pelvic  presentation  are  not  very 
accurate,  nor  are  they  in  all  cases  used  by  different  authorities 
in  the  same  sense.  The  term  '  breech  presentation '  should  be 
reserved  for  cases  in  which  the  breech  alone  presents,  the  thighs 
being  flexed  on  the  abdomen  and  the  lower  legs  extended. 
Here  we  use  it  in  this  sense  alone,  but  many  writers  use  it  as 
an  inclusive  term  for  any  form  of  pelvic  presentation.  The  term 
'  foot  presentation '  includes  all  cases  in  which  one  or  both  feet 
present  ;  and  the  term  '  knee  presentation '  includes  all  cases  in 
which  one  or  both  knees  present.  Accordingly,  we  shall  divide 
incomplete  pelvic  presentations  into  the  following  groups  : — 


THE  FREQUENCY  OF  PELVIC  PRESENTATION 


401 


(a)  Breech  Presentation. — The  breech  alone  presents,  the  thighs 
being  flexed  on  the  abdomen  and  the  legs  extended. 

(b)  Foot  or  Footling  Presentation. — One  or  both  thighs  and 
legs  are  fully  extended,  so  making  one  or  both  feet  the  presenting 
part  (v.  Fig.  234). 

(c)  Knee  Presentation. — One  or  both  thighs  are  extended,  the 


Fig.  234. — A  Footling  Presentation. 

legs  being  flexed,  so  making  one  or  both  knees  the  presenting 
part. 

Frequency. — -The  relative  frequency  of  pelvic  presentation  is 
affected  to  a  marked  extent  by  the  period  of  pregnancy  at  which 
delivery  takes  place,  and  by  the  number  of  children  the  woman 
has  previously  borne.  As  has  been  already  pointed  out,  towards 
the  end  of  the  first  half  of  pregnancy  the  tendency  of  a  foetus  is  to 
present  by  its  pelvic  pole,  on  account  of  the  better  adaptation 

26 


402 


THE  PHYSIOLOGY  OF  LABOUR 


which  then  results  between  the  foetus  and  the  uterus.  In  the  later 
months,  on  the  other  hand,  for  the  same  reason  pelvic  presentation 
but  rarely  occurs,  and  then  only  as  the  result  of  some  interference 
with  the  conditions  which  normally  cause  a  head  presentation. 
Thus,  Pinard  found  among  100,000  cases  of  labour,  in  which  all 
deliveries  were  included  independent  of  the  period  of  pregnancy 
at  which  they  took  place,  3,301  pelvic  presentations,  or  a  propor- 
tion of  about  1  in  30.  When,  however,  he  excluded  all  premature 
and  immature  cases,  the  proportion  dropped  to   1  in  62.     The 


Fig.  235.— First  Pelvic  Presentation,  the  Back  Behind.     (Faraboeuf.) 


effect  of  primiparity  or  multiparity  upon  the  proportion  is  not 
so  marked,  but  still  is  usually  considered  to  be  considerable.  The 
statistics  of  Winckel  show  that  the  proportion  of  pelvic  presenta- 
tions amongst  primiparae  is  about  1  in  80,  and  amongst  multipara 
about  1  in  23  ;  and  most  other  writers,  though  they  may  not 
consider  the  difference  to  be  so  marked,  still  consider  that  multi- 
parity  is  a  predisposing  cause.  Accordingly,  the  statistics 
furnished  by  Lepage  *  from  the  Clinic  Baudelocque  come  as 
somewhat   of    a    surprise.       During    a    fixed    period    he    found 

*  '  Precis  d'Obstetrique,'  p.  446. 


THE  FREQUENCY  OF  PELVIC  PRESENTATION 


403 


102  pelvic  presentations  occurring  in  primiparae,  and  72  in  multi- 
para?. He  does  not  tell  us  the  exact  number  of  primiparse  and 
multipara?  which  were  confined,  but  merely  states  that  there  were 
a  greater  number  of  multipara?.  These  figures  would  suggest 
that  only  primiparae  whose  pregnancy  had  been  pathological  or 


Fig.  236. — First  Pelvic  Presentation,  with  the  Back  Behind. 
The  breech  presenting  at  the  brim,  as  felt  by  vaginal  examination. 


who  suffered  from  a  contracted  pelvis  were  admitted  into  the 
clinic. 

The   following   table  shows  the  relative   frequency  of   pelvic 
presentation  at  the  different  months  of  pregnancy  : — * 


Month. 

Number  of  Pelvic 
Presentations. 

Number  of  Vertex 
Presentations. 

Percentage  of  Pelvic 
Presentations. 

Fifth    - 

Sixth  and  seventh 

Eighth  and  ninth 

Tenth  - 

Full  term 

5 
8 
6 

9 

27 

4 

17 

73 

203 

1,681 

55-5 

32-0 

7-6 

4'25 

1  "5 

The  relative  frequency  of  the  different  varieties  of  pelvic 
presentation  is  more  difficult  to  ascertain,  inasmuch  as  in  many 
lists  of  statistics  they  are  not  taken  into  account,  all  cases  being 
merely    classed   as   pelvic    presentations.      At    Guy's    Hospital 


*  Winckel,  'Text-Book  of  Midwifery,'  p.  173. 


26- 


404 


THE  PHYSIOLOGY  OF  LABOUR 


complete  pelvic  presentation  and  breech  presentations,  grouped 
together,  occurred  once  in  58  labours  and  constituted  68  per  cent, 
of  all  pelvic  presentations,  while  knee  and  foot  presentations, 
taken  together,   occurred  once  in    121    presentations.     Lepage's 


Fig.  237. — Second  Pelvic  Presentation,  the  Back  in  Front.    (Faraboeuf.) 

statistics,  to  which  we  have  already  referred,  give  the  following 
figures  : — 


Primiparag. 

Multipara. 

Total  number  of  pelvic  presentations   - 

102 

72 

Complete  presentations 

28 

27 

Incomplete  presentations — 
Breech  presentations 

70 

36) 

Foot  presentations 
Knee  presentations 

3h74 

7J44 

Unknown  presentations 

— 

1 

THE  CAUSES  OF  PELVIC  PRESENTATION 


405 


The  statistics  of  the  Rotunda  Hospital  show  that  amongst 
19,293  confinements,  in  which  all  cases  of  labour,  save  abor- 
tions, are  included,  pelvic  presentation  occurred  677  times,  or 
a  proportion  of  1  in  28*5. 

ALtiology. — We  have  already  seen,  when  discussing  the  causes 
of  the  overwhelming  proportion  of  cephalic  over  pelvic  presenta- 
tion, that  the  associated  causes  which  produce  cephalic  presenta- 
tion are  three  in  number  : — 

(1)  The  relation  between  the  shape  of  the  fcetus  and  the  shape 
of  the  uterus. 

(2)  The  effect  of  gravity  upon  the  fcetus. 


Fig.  238. — Second  Pelvic  Presentation,  with  the  Back  in  Front. 
The  breech  presenting  at  the  brim,  as  felt  by  vaginal  examination. 


(3)  The  movements  of  the  fcetus. 

Accordingly,  we  may  now  expect  to  find  that  pelvic  presenta- 
tion may  be  caused  by  certain  alterations  in  these  causes,  and 
experience  shows  that  this  is  so.  The  causes  of  pelvic  presenta- 
tion may  be  divided  into  three  groups  : — 

(1)  Alterations  in  the  normal  relation  between  the  shape  of  the 
fcetus  and  the  shape  of  the  uterus. 

(2)  Alterations  in  the  effect  of  gravity  upon  the  fcetus. 

(3)  Cessation  of  the  foetal  movements. 

In  the  first  of  these  groups,  we  must  place  all  conditions  which 
tend  to  make  the  capacity  of  the  pelvic  pole  of  the  uterus  equal 
to  or  greater  than  its  fundal  pole,  and  all  conditions  which  make 
the  cephalic  pole  of  the  fcetus  equal  to  or  greater  than  its  pelvic 
pole.     These  causes  are  as  follows  : — 


406 


THE  PHYSIOLOGY  OF  LABOUR 


(a)  Causes  which  Affect  the  Uterus. — Multiparity,  by  causing 
a  large  lax  uterus  ;  tumours  of  the  uterus  ;  over-distension,  as  in 
twins  or  hydramnios  ;  contracted  pelvis,  by  preventing  the  head 
from  descending  and  adapting  itself  to  the  lower  pole  of  the 
uterus ;  placenta  praevia,  by  acting  in  a  similar  manner  to  the 
foregoing  ;  congenital  malformations  of  the  uterus. 

(b)  Causes  which  Affect  the  Fcetus. — Hydrocephalic  head,  by 
making  the  cephalic  pole  larger  than  the  pelvic ;  cystic  enlarge- 


Fig.  239. — Second  Pelvic  Presentation,  the  Back  Behind.    (Farabceuf.) 


ment  of  the  upper  portion  of  the  foetal  body ;  premature  or 
macerated  foetus. 

In  the  second  main  group  of  causes  of  pelvic  presentation,  we 
must  place  a  few  conditions  which  so  alter  the  foetal  body  that 
the  pelvic  pole  is  heavier  than  the  cephalic.  The  principal  of 
these  causes  are  premature  and  macerated  foetus  in  which  the 
specific  gravity  of  the  head  is  diminished  relatively  to  that  of  the 
breech  ;  and  cystic  enlargement  of  the  fcetal  bladder  or  kidneys. 

In  the  third  main  group  of  causes,  only  one  condition  is  to  be 
found,  and  that  is  a  dead  fcetus,  owing  to  the  absence  of  the  move- 
ments of  the  limbs  which  tend  to  produce  a  cephalic  presentation. 

The  principal  cause  of  a  foot  or  a  knee  presentation  is  stated 


THE  DIAGNOSIS  OF  PELVIC  PRESENTATION  407 

to  be  an  oblique  lie  of  the  foetus  prior  to  the  onset  of  labour. 
If  in  such  a  case  the  cephalic  pole  of  the  foetus  lies  lower  than 
the  pelvic  pole,  an  arm  tends  to  prolapse  ;  if  the  pelvic  pole  is  the 
lower,  a  leg  (Herman). 

Positions. — The  foetus  may  lie  in  one  of  two  positions  according 
as  the  back  is  turned  to  the  left  or  to  the  right  side,  and  each  of 
these  positions  may  be  again  sub-divided  into  two  more  according 
as  the  back  is  directed  anteriorly  or  posteriorly.  The  different 
positions  may  be  tabulated  as  follows  : — 

'  In  front,  first  position  of  Naegele,  some- 
times termed  left  sacro-anterior,  or 
L.S.A. 


First  position,  back  to  the  left 


Second  position,  back  to  the  right 


Behind,  fourth  position  of  Naegele,  left 
sacro-posterior,  or  L.  S.P. 

In  front,  second  position  of  Naegele,  right 
sacro-anterior,  or  R.S.A. 


Behind,  third  position  of  Naegele,  right 
^     sacro-posterior,  or  R. S.P. 

If  Naegele's  classification  is  adopted  the  sacrum  is  used  as 
the  indicator,  as  is  the  occiput  in  vertex  presentation,  or  the 
chin  in  face  presentation.  The  first  position  is  slightly  more 
common  than  the  second,  and  the  back  is  usually  directed 
anteriorly.  Amongst  284  cases  recorded  at  different  times  by 
Winckel*  and  Hecker,  the  first  position  occurred  155  times  and 
the  second  position  129  times,  or  a  proportion  of  1-2  to  1  in 
favour  of  the  first  position.  This  is  very  different  from  the 
relative  frequency  of  the  two  positions  found  in  vertex  presenta- 
tion, in  which,  according  to  Winckel,!  the  proportion  of  the 
first  position  to  the  second  is  as  647  to  35-3,  or,  roughly,  as 
g  to  5.  This  relative  equality  in  the  frequency  of  the  two  posi- 
tions in  pelvic  presentation  is  probably  due  to  the  fact  that  here 
one  of  the  important  causes  of  the  high  proportion  of  first 
position  in  vertex  presentation  is  wanting.  The  right  oblique 
diameter  of  the  pelvis  is  longer  than  the  left,  and,  consequently, 
in  vertex  presentation  the  longer  engaging  diameter  of  the  head — ■ 
i.e.,  the  occipito-mental  diameter — finds  more  room  in  it  than  in 
the  left  oblique  diameter.  In  the  first  position  in  pelvic  presenta- 
tion, on  the  other  hand,  the  long  diameter  of  the  pelvic  pole  of 
the  foetus — i.e.,  the  bi-trochanteric  diameter — has  to  lie  in  the 
left  oblique  diameter  of  the  pelvis,  i.e.,  in  the  shorter  of  the  two 
diameters. 

Diagnosis. — The  diagnosis  of  pelvic  presentation  can  be  made 
by  abdominal  palpation,  vaginal  examination,  and  auscultation. 

Abdominal  Palpation. — The  cephalic  pole  of  the  foetus  is  found 
at  the  fundus  of  the  uterus  and  is  recognised  by  the  following 
signs:  — 

*  Op.  tit.,  p.  170.  t  Ibid.,  p.  154. 


408  THE  PHYSIOLOGY  OF  LABOUR 

(i)  The  head  is  more  round,  more  uniform  in  outline,  and 
firmer  than  the  breech. 

(2)  It  is  also  more  movable,  and  can  be  ballotted  from  side  to 
side  if  the  membranes  are  intact. 

(3)  It  is  separated  from  the  back  by  a  deep  groove — the  groove 
of  the  neck. 

Of  the  three  signs  the  determination  of  the  groove  of  the  neck 
is  the  most  important. 

The  lie  of  the  foetus  is  found  to  be  longitudinal,  with  the  back 
directed  to  one  or  other  side,  according  to  the  position.  The 
pelvic  pole  is  found  in  the  lower  pole  of  the  uterus,  if  it  has  not 


Fig.  240. — Second  Pklvic  Presentation,  the  Back  Behind. 
The  breech  presenting  at  the  brim,  as  felt  by  vaginal  examination. 

passed  through  the  brim.  If  it  can  be  palpated  it  is  distinguished 
from  the  head  by  its  greater  size,  by  the  presence  of  the  thighs, 
by  the  absence  of  the  groove  of  the  neck,  and  by  the  impossibility 
of  obtaining  ballottement.  The  feet  can  sometimes  be  felt  lying 
at  or  near  the  pelvic  brim. 

Vaginal  Examination.  —  At  the  commencement  of  labour  it 
may  be  difficult  to  reach  the  presenting  part  owing  to  its  high 
situation,  but  as  it  descends,  its  nature  can  be  determined. 
The  diagnostic  points  are  the  tuberosities  of  the  ischium  ^and  the 
tip  of  the  coccyx,  the  groove  of  the  nates,  the  anus,  and  the 
external  genitals.  The  anus  may  be  mistaken  for  the  mouth,  and 
can  be  distinguished  from  the  latter  as  has  been  already  men- 
tioned. In  some  cases,  where  labour  has  lasted  for  a  considerable 
time  and  a  large  caput  succedaneum  has  formed  on  the  present- 


THE  DIAGNOSIS  OF  PELVIC  PRESENTATION  409 

ing  part,  there  may  be  some  difficulty  in  distinguishing  between 
a  face  and  a  breech.  If,  however,  the  fingers  are  passed  upwards 
beside  the  presenting  part  a  diagnosis  will  readily  be  made,  as  in 
the  case  of  a  face  we  shall  come  upon  the  ear,  in  the  case  of 
a  breech  upon  the  groove  between  the  thighs  and  the  trunk  and 
upon  the  crest  of  the  ilium.  If  a  limb,  or  any  part  of  one,  is  found 
in  the  vagina,  we  must  determine  first  what  limb  or  part  of  one  it 
is,  and,  secondly,  to  what  side  it  belongs.  We  have  already  men- 
tioned the  diagnostic  points,  but  it  may  be  well  to  repeat  them. 


Fig.  241. — Diagram  representing  the  Fcetus  as  felt  by  Abdominal 
Palpation  in  Pelvic  Presentation. 

The  unshaded  portions  of  the  foetus  are  those  that  are  felt  most  distinctly. 

A  hand  is  relatively  smaller  than  a  foot,  the  outline  of  the  tops  of 
the  fingers  is  curved,  and  the  thumb  can  be  apposed  and  opposed 
to  the  palm.  In  a  foot,  on  the  other  hand,  the  outline  of  the  tops 
of  the  toes  is  straight,  the  articulations  of  the  great-toe  do  not 
permit  any  lateral  movement,  and  the  shape  of  the  os  calcis  and 
its  relation  to  the  malleoli  are  quite  characteristic.  The  elbow 
is  relatively  smaller  than  the  knee,  the  olecranon  process  is  im- 
mobile, while  the  patella  can  be  moved  if  the  knee  is  not  strongly 
flexed.  Further,  in  the  case  of  the  knee,  the  patellar  ligament 
and  the  tuberosity  on  the  tibia  can  be  felt.     The  side  to  which 


410  THE  PHYSIOLOGY  OF  LABOUR 

a  foot  belongs — i.e.,  whether  it  is  right  or  left — can  readily  be 
determined  by  inspection  if  the  foot  has  passed  outside  the  vagina. 
If  it  is  still  in  the  vagina,  the  side  can  be  determined  by  noting 
the  position  which  the  great-toe  occupies  upon  it,  and  then  men- 
tally comparing  it  with  the  position  the  great-toe  occupies  respec- 
tively on  a  right  or  left  foot.  A  complete  pelvic  presentation  is 
diagnosed  by  finding  the  feet  lying  beside  the  breech ;  a  breech 
presentation  by  finding  the  breech  alone  ;  and  a  foot  or  a  knee 
presentation  by  finding  respectively  the  foot  or  the  knee  lying 
lowest. 

The  position  of  the  foetus  can  be  determined  by  noting  the 
side  of  the  pelvis  at  which  the  coccyx  or  the  external  genitals  are 
found. 

Auscultation. — At  the  commencement  of  labour,  before  the 
breech  has  descended  into  the  pelvis,  the  heart  is  heard  slightly 
above  the  umbilicus  and  to  one  or  other  side  of  the  uterus, 
according  to  the  side  to  which  the  back  is  turned.  As  the  breech 
descends,  it  is  heard  at  a  correspondingly  lower  level. 

Mechanism. — The  mechanism  of  a  pelvic  presentation  differs 
in  one  important  detail  from  the  mechanism  of  a  cephalic 
presentation,  in  that  the  movements  of  flexion  and  extension, 
which  are  of  such  importance  in  the  latter  presentation,  are  in 
pelvic  presentation  of  necessity  absent.  As  the  breech  and  trunk 
already  constitute  a  single  and  more  or  less  rigid  body,  there 
is  no  necessity  for  the  initial  movement  by  which,  in  cephalic 
presentation,  the  head  and  trunk  are  temporarily  brought  into 
rigid  coaptation,  and,  consequently,  in  a  pelvic  presentation, 
there  is  no  analogue  to  the  inital  flexion  or  extension  of  cephalic 
presentation.  For  the  later  extension  or  flexion,  by  which  the 
head  follows  the  curve  of  the  genital  canal  and  passes  through 
the  vulva,  there  is  an  analogue  in  pelvic  presentation,  inasmuch 
as  the  curve  of  the  pelvis  must  be  followed,  and  this  is  found  in 
a  latero-flexion  of  the  body  of  the  foetus  in  a  direction  corre- 
sponding to  the  pelvic  curve.  Similarly,  internal  rotation  occurs 
in  pelvic  as  in  cephalic  presentation  in  order  to  maintain  the  long 
diameters  of  the  foetal  pelvis  in  the  long  diameters  of  the  maternal 
pelvis,  and  results  in  the  rotation  of  the  bi-trochanteric  diameter 
of  the  foetus  from  one  or  other  oblique  diameter  into  the  antero- 
posterior diameter  of  the  maternal  pelvis.  Lastly,  external 
rotation  occurs  as  before,  in  consequence  of  internal  rotation  of 
the  shoulders.  We  shall  now  describe  these  various  movements 
in  greater  detail. 

Descent. — Under  the  influence  of  the  uterine  contractions  the 
pelvic  pole  of  the  foetus  descends  into  the  pelvic  brim  of  the 
mother,  the  bi-trochanteric  diameter  corresponding  to  one  of  the 
maternal  oblique  diameters  (v.  Fig.  242).  If  it  is  a  case  of  complete 
pelvic  presentation,  the  pre-existing  flexion  of  the  lower  limbs  is 
increased,  and  the  latter  are  pressed  strongly  against  the  foetal 
body.     In  some  cases,  the  feet  may  catch  against  the  brim  and  be 


THE  MECHANISM  OF  PELVIC  PRESENTATION 


411 


pushed  upwards  as  the  breech  descends,  the  presentation  thus  being 
converted  from  a  complete  pelvic  presentation  to  a  presentation 
of  the  breech  alone.  As  the  breech  passes  into  the  pelvis,  the 
anterior  buttock  lies  at  a  slightly  lower  level  than  the  posterior. 

Internal  Rotation. — As  a  result  of  its  lower  position,  the  anterior 
buttock  reaches  the  pelvic  floor  first,  and  then,  obedient  to  the 
rule  of  internal  rotation,  rotates  in  front,  so  that  the  bi-trochan- 


Fig.  242. — The  Mechanism  of  First  Pelvic  Presentation. 

The   pelvic  pole  engaging  in  the  brim,  its  antero-posterior  diameters  corre- 
sponding to  the  left  oblique  diameters  of  the  pelvis. 


teric  diameter,  which  up  to  this  corresponded  to  the  oblique  diameter 
of  the  pelvis,  now  corresponds  with  the  antero-posterior  diameter, 
and  the  anterior  hip  lies  beneath  the  symphysis  (v.  Fig.  243). 
Internal  rotation  in  a  pelvic  presentation  never  occurs  through 
more  than  one-eighth  of  a  circle,  as  no  matter  what  the  position 
of  the  foetus,  the  anterior  hip  always  rotates  in  front. 

Latero-flexion  of  the  Trunk. — In  order  that  the  presenting  part 


412 


THE  PHYSIOLOGY  OF  LABOUR 


may  follow  the  curve  of  the  pelvis,  a  movement  similar  to  the 
flexion  or  extension  of  the  head  under  the  same  circumstances 
must  occur.  This  movement  consists  in  a  strong  latero-flexion 
of  the  body,  by  means  of  which  the  anterior  buttock  passes 
beneath  the  symphysis,  appears  at  the  vulva,  and  is  born.  The 
posterior  buttock  in  the  meantime  is  distending  the  perinaeum, 
and  then  the  latero-flexion  of  the  trunk  continuing,  it  moves 
forward   and   in    turn   is   born.       If  the   perinaeum    is   deficient 


Fig.  243. — The  Mechanism  of  First  Pelvic  Presentation. 
The  breech  has  reached  the  pelvic  floor,  and  internal  rotation  has  occurred. 


owing  to  previous  laceration,  the  posterior  buttock  may  be  born 
first,  but,  under  normal  circumstances,  the  sequence  that  we  have 
described  is  found,  save  in  the  case  of  a  small  infant,  when  both 
buttocks  may  appear  simultaneously.  In  the  case  of  a  com- 
plete pelvic  presentation,  the  feet  emerge  alongside  the  buttocks. 

External  Rotation. — As  soon  as  the  breech  is  free  from  the 
restraint  imposed  by  the  pelvic  walls  restitution  occurs,  and  the 
bi-trochanteric  diameter  returns  to  its  former  position,  only  to 
again  rotate  back  into  the  antero-posterior  diameter  of  the  outlet 


THE  MECHANISM  OF  PELVIC  PRESENTATION  413 

in  association  with  the  internal  rotation  of  the  shoulders.  Both 
these  movements  are,  however,  less  marked  than  they  are  in 
cephalic  presentation. 

Expulsion  of  the  Trunk  and  Head. — If  the  further  expulsion  of 
the  fcetus  is  left  to  the  natural  efforts,  and  if  no  traction  is  made 


Fig.  244. — The  Mechanism  of  First  Pelvic  Presentation. 

The  pelvic  pole  of  the  foetus  has  been  expelled,  and  the  shoulders  are 
descending  in  the  left  oblique  diameter  of  the  pelvis. 

upon  the  part  already  born,  the  trunk  is  gradually  expelled,  the 
arms  folded  across  the  chest.  The  bis-acromial  diameter  of  the 
shoulders  passes  through  the  brim  in  the  same  oblique  diameter 
of  the  brim  as  did  the  bi-trochanteric  (v.  Fig.  244),  and  as  the 


4U  THE  PHYSIOLOGY  OF  LABOUR 

shoulders  reach  the  outlet,  it  rotates  into  the  antero-posterior 
diameter,  the  anterior  shoulder  turning  forwards.  The  head  passes 
through  the  pelvis  in  a  position  of  flexion,  which  is  maintained  by 
the  contractions  of  the  uterus.  Its  antero-posterior  diameters  pass 
through  the  brim  in  the  opposite  oblique  diameter  to  that  traversed 
by  the  transverse  diameters  of  the  pelvis  and  shoulders.  As  the 
pelvic  floor  is  reached,  the  occiput  rotates  in  front,  and  the  nape 
of  the  neck  lies  behind  and  below  the  symphysis.  The  head  then 
rotating  round  the  lower  margin  of  the  latter  is  born,  with  its 
antero-posterior  diameters  corresponding  to  the  antero-posterior 
diameters  of  the  outlet.  The  chin  appears  first,  then  the  face, 
sinciput,  and  vertex,  and  lastly  the  occiput. 

The  delivery  of  the  head  is,  however,  not  always  a  simple 
matter.  As  it  descends  into  the  pelvic  cavity  it  passes  out  of  the 
uterus,  and,  consequently,  cannot  be  acted  upon  by  the  con- 
tractions of  the  latter.  The  motive  power  by  which  its  expulsion 
is  caused  is  thus  seriously  curtailed,  and  consists  solely  in  the 
force  supplied  by  the  contractions  of  the  voluntary  muscles  of 
labour.  This  force  in  some  cases  may  be  sufficient,  but  it  cannot 
be  relied  upon,  as  the  welfare  of  the  child  imperatively  demands  the 
rapid  passage  of  the  head  through  the  pelvis.  Consequently,  we 
shall  see,  when  discussing  the  management  of  pelvic  presentation, 
that  the  delivery  of  the  after-coming  head  from  the  vagina  must 
be  as  systematically  assisted  as  is  the  delivery  of  the  placenta. 

The  foregoing  general  description  of  the  mechanism  of  a  pelvic 
presentation  applies  generally  to  all  positions  of  the  foetus.  We 
must  now  describe  the  mechanism  of  the  different  positions 
separately. 

First  Position,  Back  to  the  Left. — In  the  first  position,  with  the 
back  in  front,  the  first  position  of  Naegele,  or  the  right  sacro- 
anterior, the  breech  enters  the  pelvis  with  its  bi-trochanteric 
diameter  corresponding  to  the  left  oblique  diameter  of  the  pelvis. 
Descent  occurs,  and  the  breech  remains  in  the  same  position 
until  the  pelvic  floor  is  reached,  the  anterior  hip  lying  slightly 
lower  than  the  posterior  hip.  Internal  rotation  then  occurs,  and 
the  anterior  hip  moves  forwards  from  the  anterior  end  of  the  left 
oblique  diameter  to  lie  beneath  the  symphysis.  Latero-flexion  of 
the  trunk  towards  its  left  side  occurs  next,  the  buttocks  appear  at 
the  vulva,  and  the  breech  is  born,  as  has  been  described.  Re- 
stitution brings  back  the  bi-trochanteric  diameter  to  its  former 
position.  The  trunk  then  follows,  the  bis-acromial  diameter  of 
the  shoulders  rotating  from  the  left  oblique  diameter  into  the 
antero-posterior  diameter  of  the  outlet,  and  producing  a  similar 
rotation  of  the  breech  externally.  The  head  descends  with  its 
antero  -  posterior  diameters  corresponding  to  the  right  oblique 
diameters  of  the  brim.  As  the  pelvic  floor  is  reached,  the  occiput 
rotates  from  the  anterior  end  of  the  right  oblique  diameter  to  lie 
under  the  symphysis,  and  then  the  head,  pivoting  round  this 
point,  is  born. 


THE  MECHANISM  OF  PELVIC  PRESENTATION  415 

In  the  first  position,  with  the  back  behind,  fourth  position  of 
Naegele,  or  the  left  sacro-posterior,  the  breech  enters  the  pelvis 
with  its  bi-trochanteric  diameter  corresponding  to  the  right  oblique 
diameter  of  the  brim.  Descent  occurs,  and  as  soon  as  the  pelvic 
floor  is  reached,  the  anterior  hip  rotates  forward  from  the  anterior 
end  of  the  right  oblique  diameter  to  lie  beneath  the  symphysis. 
The  breech  is  then  born,  with  accompanying  latero-flexion  of  the 
body  towards  its  left  side.  Restitution  frequently  causes  a  rota- 
tion in  a  similar  direction  to  that  in  which  internal  rotation 
occurred,  instead  of,  as  is  usual,  in  the  reverse  direction.  That  is 
to  say,  the  anterior  hip  turns  from  beneath  the  symphysis  to  lie 
at  the  anterior  end  of  the  left  oblique  diameter.  This  movement 
is  probably  the  result  of  a  movement  of  the  fcetal  trunk  with  the 
object  of  adapting  its  spinal  curve  to  the  spinal  curve  of  the 
mother.  As  a  result,  the  shoulders  descend  in  the  left  oblique 
diameter  of  the  brim,  until  the  pelvic  floor  is  reached,  when  the 
anterior  shoulder  rotates  from  the  anterior  end  of  the  left  oblique 
diameter  to  lie  beneath  the  symphysis.  The  head  descends  with 
its  antero-posterior  diameters  in  the  right  oblique  diameter  of  the 
pelvis,  the  occiput  turned  forwards,  and  from  this  position  they 
rotate  into  the  anteroposterior  diameter  as  the  pelvic  floor  is 
reached.  The  head  is  finally  born  as  before.  In  some  cases 
restitution  occurs  in  the  usual  direction — that  is  to  say,  in  the 
reverse  direction  to  that  in  which  internal  rotation  occurred — and 
the  anterior  hip  rotates  back  again  to  the  left  side.  In  such 
cases  the  shoulders  engage  in  the  right  oblique  diameter,  and  the 
head  with  its  antero  -  posterior  diameters  in  the  left  oblique 
diameter,  with  the  occiput  turned  backwards,  or  perhaps  in  the 
transverse  with  the  occiput  pointing  towards  the  left  side.  In 
consequence,  the  head  has  to  rotate  through  three-eighths  or 
through  one-half  of  a  circle  to  bring  the  occiput  behind  the 
symphysis. 

Second  Position,  Back  to  the  Right. — In  the  second  position, 
with  the  back  in  front,  second  position  of  Naegele,  right  sacro- 
anterior, the  breech  enters  the  pelvis  with  its  bi-trochanteric 
diameter  corresponding  to  the  right  oblique  diameter.  Descent 
occurs,  and  as  soon  as  the  pelvic  floor  is  reached  the  anterior  hip 
rotates  from  the  anterior  end  of  the  right  oblique  diameter  of  the 
pelvis  to  lie  beneath  the  symphysis.  The  breech  is  then  expelled 
with  an  accompanying  latero-flexion  of  the  body  towards  its  right 
side.  A  slight  degree  of  restitution  occurs,  and  brings  the  anterior 
hip  back  to  its  former  position.  The  trunk  follows,  the  bis- 
acromial  diameter  passing  through  the  brim  in  the  right  oblique 
diameter,  and  then  rotating  into  the  antero-posterior  diameter  as 
the  pelvic  floor  is  reached.  The  head  descends  with  its  antero- 
posterior diameter  in  the  left  oblique  diameter  of  the  brim,  the 
occiput  directed  forwards.  As  the  pelvic  floor  is  reached,  the 
occiput  rotates  from  the  anterior  end  of  the  left  oblique  diameter 
to  lie  beneath  the  symphysis,  and  the  head,  pivoting  round  it,  is 
born. 


41 6  THE  PHYSIOLOGY  OF  LABOUR 

In  the  second  position,  with  the  back  posterior,  third  position  of 
Naegele,  right  sacro-posterior,  the  bi-trochanteric  diameter  passes 
through  the  brim  in  the  left  oblique  diameter  of  the  brim. 
Descent  occurs,  and,  as  the  pelvic  floor  is  reached,  the  anterior 
hip  rotates  forwards  from  the  anterior  end  of  the  left  oblique 
diameter  to  lie  beneath  the  symphysis.  The  breech  is  then  born 
with  an  accompanying  latero-flexion  of  the  body  towards  its  right 
side.  As  in  the  first  position  with  the  back  posterior,  restitution 
not  uncommonly  causes  a  rotation  in  the  same  direction  as  that 
in  which  internal  rotation  occurred — that  is  to  say,  the  anterior 
hip  rotates  towards  the  mother's  left  side.  The  shoulders,  conse- 
quently, pass  through  the  brim  in  the  right  oblique  diameter  of 
the  brim,  and  the  anterior  shoulder  rotates  from  the  anterior  end 
of  the  right  oblique  diameter  to  lie  beneath  the  symphysis.  The 
head  then  descends,  with  its  antero-posterior  diameters  lying  in 
the  left  oblique  diameter  of  the  brim,  and  the  occiput  rotates  from 
the  anterior  end  of  this  diameter  through  one-eighth  of  a  circle  to 
lie  beneath  the  symphysis.  Finally,  the  head,  pivoting  round 
this  point,  is  born  as  before.  In  some  cases,  restitution  may  occur 
in  the  usual  direction — that  is  to  say,  in  the  reverse  direction  to 
that  in  which  internal  rotation  occurred,  and  consequently, 
the  anterior  hip  rotates  back  to  its  original  position.  As  a 
result,  the  shoulders  engage  in  the  left  oblique  diameter,  and  the 
antero-posterior  diameters  of  the  head  in  the  right  oblique,  the 
occiput  directed  backwards.  Consequently,  the  occiput  has  to 
rotate  from  the  posterior  end  of  this  diameter  through  three- 
eighths  of  a  circle  to  lie  beneath  the  symphysis. 

Abnormalities  of  Mechanism  in  Pelvic  Presentation. — The  occurrence 
of  a  foot  and  a  knee  presentation  must  strictly  be  regarded  as  an 
abnormality  in  the  mechanism  of  a  pelvic  presentation,  but  as 
such  an  occurrence  affects  the  ordinary  mechanism  to  a  very 
slight  extent,  it  is  unnecessary  to  discuss  it  separately.  The  only 
abnormality  of  any  importance  consists  in  a  reversed  rotation  of 
the  head. 

Reversed  Rotation  of  the  Head. —  In  certain  cases  —  most 
probably  in  those  in  which  the  back  of  the  foetus  was  directed 
posteriorly — the  occiput,  instead  of  rotating  anteriorly  and  lying 
beneath  the  symphysis,  rotates  posteriorly  into  the  hollow  of  the 
sacrum.  In  such  cases,  the  face  sometimes  lies  behind  the 
symphysis,  and  at  other  times  the  chin  hitches  above  the  sym- 
physis, and  the  face  looks  upwards.  The  expulsion  of  the  head 
will  in  all  probability  never  take  place  if  left  to  the  natural  efforts. 
As  we  shall  presently  see,  when  the  face  lies  behind  the  pubis 
delivery  can  be  best  obtained  by  first  drawing  the  face  down- 
wards, the  occiput  being  the  last  part  born.  When,  on  the  other 
hand,  the  chin  has  caught  above  the  symphysis,  we  must 
endeavour  to  cause  the  head  to  descend  in  the  reverse  manner, 
the  occiput  first  passing  over  the  perinaeum,  then  the  vertex  and 
face,  and  lastly  the  chin. 


THE  MANAGEMENT  OF  PELVIC  PRESENTATION  417 

Moulding. — The  moulding  of  the  after-coming  head  in  a  pelvic 
presentation  is  not  carried  to  any  marked  extent,  owing  to  the 
short  period  during  which  it  is  exposed  to  the  pressure  of  the 
pelvic  walls.  Any  moulding  which  does  take  place  results  in  the 
diminution  of  the  fronto-occipital  and  mento-occipital  diameters, 
and  in  a  compensatory  increase  in  the  cervico-bregmatic  and  sub- 
occipito-bregmatic  diameters  (v.  Fig.  245). 

The  caput  succedaneum  forms  over  the  anterior  buttock  and 
the  genitals,  and  particularly  affects  the  scrotum  in  male  infants. 
In  some  cases,  this  part  may  become  quite  black  from  subcutaneous 
ecchymoses.     It  will,  however,  soon  regain  its  normal  condition. 

Management. — The   first    point   to    be    decided    regarding    the 


M 

C 

Fig.  245. — The  Moulding  of  the  Head  in  Pelvic  Presentation. 

The  black  outline  represents  the  unmoulded,  the  red  the  moulded  head. 

(Budin.) 

management  of  a  pelvic  presentation  is  the  advisability  or  other- 
wise of  allowing  the  pelvic  presentation  to  persist.  As  we  shall 
presently  see,  when  discussing  the  maternal  and  foetal  prognosis,  a 
pelvic  presentation  is  always  a  source  of  danger  to  the  foetus, 
although,  so  far  as  the  mother  is  concerned,  it  is  no  more 
dangerous  than  a.  vertex  presentation.  Accordingly,  it  is  only 
for  the  sake  of  the  foetus  that  we  need  consider  the  necessity 
of  changing  the  presentation.  At  first  sight  it  appears  to  be 
obvious  that,  for  the  sake  of  the  foetus,  we  should  always  change 
a  pelvic  into  a  vertex  presentation  ;  but  a  little  consideration  will 
show  us  that  it  is  not  correct  to  compare  the  foetal  mortality 
which  occurs  in  vertex  presentation,  when  presumably  all  the 
conditions  of  labour  are  normal,  with  the  mortality  that  occurs  in 
pelvic  presentation,  when  presumably  there  is  some  abnormal 
factor  present  which    has   been    the  direct  cause  of  the  pelvic 

27 


4i 8  THE  PHYSIOLOGY  OF  LABOUR 

presentation.  It  is  quite  correct  to  assume  that,  if  we  meet  with 
a  pelvic  presentation  under  conditions  which  are  normal  in  every 
way  save  as  regards  the  presentation,  we  shall  reduce  the  foetal 
mortality  by  correcting  the  presentation,  but  we  cannot  make 
this  assumption  in  the  greater  proportion  of  cases  of  pelvic  pre- 
sentation. Contraction  of  the  pelvis,  for  instance,  is  a  common 
cause  of  pelvic  presentation,  and  in  certain  forms  and  degrees  of 
contraction  the  foetal  mortality  will  be  less  if  the  presentation  is 
pelvic  than  if  it  is  a  vertex.  Placenta  praevia  is  another  cause,  and, 
in  such  cases,  if  the  vertex  presents,  it  is  frequently  necessary  to 
bring  about  a  pelvic  presentation.  Accordingly,  we  may  definitely 
state  that,  in  certain  cases,  the  foetal  prognosis  will  not  be  improved 
by  changing  a  pelvic  into  a  vertex  presentation.  Further,  it 
is  often  impossible  to  correct  the  presentation,  either  because  we 
do  not  see  the  patient,  or  do  not  diagnose  the  presentation,  until 
too  late.  Lastly,  there  are  some  cases  in  which  the  difficulty  of 
correcting  the  presentation,  even  though  the  presenting  part  is 
not  fixed,  may  be  so  great  as  to  render  it  either  impossible  or 
inadvisable  to  try  to  do  so.  It  will  thus  be  readily  seen  that  the 
proportion  of  cases  in  which  it  is  both  advisable  and  possible 
to  change  a  pelvic  into  a  vertex  presentation  is  not  great.  As  a 
general  rule,  it  may  be  stated  that  version  in  these  cases  should 
only  be  performed  by  external  manipulation,  as  the  operation  of 
internal  or  combined  version  is  too  serious  a  matter  to  be  adopted 
as  a  routine  practice.  External  version,  however,  necessitates  the 
presence  of  certain  conditions  which  we  shall  presently  learn — 
notably,  a  lax  abdominal  wall — and  this  condition  is  rarely  found 
in  primiparae,  in  whom  it  is  especially  desirable  to  correct  a  pelvic 
presentation. 

We  may  sum  up  the  question  of  the  advisability  of  the  alteration 
of  a  pelvic  into  a  vertex  presentation  in  a  few  words.  If  there 
are  no  conditions  present  in  which  a  pelvic  presentation  is 
preferable,  and  if  it  is  possible  to  correct  the  presentation  by 
external  version,  it  is  advisable  to  so  correct  it.  If  it  is  decided 
to  perform  version  in  any  case,  the  most  suitable  time  is  shortly 
after  the  patient  has  come  into  labour.  It  is  of  little  use  to 
correct  a  pelvic  presentation  during  pregnancy,  as  it  will  almost 
certainly  recur,  and  if  left  until  late  in  labour  correction  by 
external  version  is  difficult  or  impossible.  When  the  head  has 
been  brought  over  the  brim,  it  must  be  held  there  until  it  fixes, 
or,  if  the  uterine  orifice  is  well  dilated,  the  membranes  may  be 
ruptured,  and  the  head  then  maintained  in  position  by  means  of 
an  abdominal  binder  tightly  applied. 

When  a  pelvic  presentation  is  allowed  to  persist,  the  obstetri- 
cian must  prepare  for  a  labour  in  which  his  skill  and  knowledge 
may  be  tested  to  a  very  considerable  extent.  Perhaps  in  no 
other  presentation  does  so  much  depend  on  the  possession  of 
these  acquirements.  In  a  vertex  presentation  the  foetus  will  in 
the  great  majority  of  cases  be  born  without  assistance.     In  a  face 


THE  MANAGEMENT  OF  PELVIC  PRESENTATION  419 

presentation  the  amount  of  assistance  which  can  be  given  is 
slight.  In  a  pelvic  presentation,  assistance  is  both  required,  and, 
if  given  in  the  proper  manner,  of  the  greatest  value. 

There  is  a  tendency  in  pelvic  presentation,  as  in  all  other 
abnormal  presentations,  to  the  occurrence  of  premature  rupture 
of  the  membranes,  consequent  on  the  fact  that  the  pelvic  pole 
does  not  fill  the  lower  uterine  segment  as  completely  as  does  the 
cephalic  pole.  Moreover,  in  pelvic  presentation  it  is  especially 
necessary  to  preserve  the  membranes  intact  until  the  dilatation  of 
the  uterine  orifice  is  as  complete  as  possible.  If  the  membranes 
rupture,  the  dilatation  of  the  orifice  is  to  a  large  extent  dependent 
on  the  pressure  of  the  breech,  and  is  not  as  complete  as  it  ought 
to  be.  Consequently,  the  incompletely  dilated  os  may  cause 
delay  during  the  expulsion  of  the  shoulders  and  head,  and  so 
increase  the  danger  of  fcetal  asphyxia.  To  avoid  premature 
rupture,  the  patient  should  be  kept  in  bed  from  as  early  a  period 
as  possible  in  the  first  stage,  especially  in  cases  in  which  the 
membranes  protrude  unduly  into  the  vagina  during  a  contraction. 
The  only  other  special  precaution,  which  need  be  taken  at  this 
time,  consists  in  making  a  vaginal  examination  towards  the  end  of 
the  first  stage,  and  again  as  soon  as  the  membranes  rupture,  to 
ascertain  that  the  cord  is  neither  presenting  nor  prolapsed. 

As  soon  as  the  breech  appears  at  the  vulva,  the  patient  should 
be  placed  in  the  cross-bed  position,  with  her  buttocks  pro- 
jecting slightly  over  the  edge  of  the  bed.  The  necessity  for 
this  precaution  will  be  obvious  when  we  come  to  discuss  the 
delivery  of  the  after-coming  head.  Before  describing  the  assist- 
ance which  must  be  given,  we  must  call  attention  to  two 
important  principles.  The  first  of  these  is  the  necessity 
for  maintaining  throughout  delivery  the  normal  mechanism  which 
has  been  already  described.  If  the  process  of  expulsion  has  to 
be  hastened  at  any  time,  this  must  be  done  in  a  manner  that 
will  not  interfere  with  this  mechanism,  as  otherwise,  instead  of 
hastening  expulsion,  we  shall  retard  it,  or  perhaps  render  it 
impossible.  The  second  principle  is  to  refrain  as  long  as  possible 
from  all  traction  upon  the  body  of  the  fcetus.  If  the  natural 
efforts  must  be  supplemented,  in  all  cases  this  should  first  be 
done  by  pressure  upon  the  fundus.  This  principle  is  really  only 
an  amplification  of  the  former  one.  It  is  impossible  to  maintain 
the  normal  mechanism  if  traction  is  made  upon  the  body  ;  but,  if 
pressure  is  applied  from  above,  the  effect  is  the  same  as  if  the 
contractions  of  the  uterus  were  increased  in  strength,  and,  con- 
sequently, there  is  no  interference  with  the  normal  mechanism. 
Traction  on  the  body  obstructs  the  normal  rotations,  and  so  tends 
to  cause  impaction  in  the  pelvic  cavity.  Further,  it  almost 
invariably  leads  to  extension  of  the  arms  of  the  fcetus.  When 
the  latter  is  expelled  by  the  uterine  contractions,  its  arms  are 
kept  in  contact  with  the  chest  by  the  pressure  of  the  uterine 
walls,  until  such  time  as  the  chest  has  passed  into  the  pelvis, 

27 — 2 


420  THE  PHYSIOLOGY  OF  LABOUR 

when  the  pressure  of  the  pelvic  walls  serves  the  same  purpose. 
When  the  fetus  is  dragged  down  by  traction  on  the  legs  or  body, 
the  controlling  pressure  of  the  uterine  walls  is  lost,  and  the  arms 
are  no  longer  pressed  against  the  chest  ;  consequently,  the  pro- 
jecting elbows  are  caught  by  the  pelvic  brim.  Then,  instead  of 
passing  through  the  pelvis  at  the  same  time  as  the  chest,  they 
are  pushed  upwards  beside  the  head,  and  if  left  in  this  position 
will  obstruct  or  altogether  prevent  the  passage  of  the  latter 
through  the  pelvis.  In  some  cases,  however,  it  is  not  always 
possible  to  obey  this  principle,  as  pressure  upon  the  fundus  may 
not  supply  the  necessary  amount  of  force  to  expel  the  foetus  ; 
then  traction  must  be  made,  and  we  must  be  prepared  for  its 
bad  consequences  and  ready  to  correct  them. 

It  is  unnecessary  to  take  the  same  precautions  for  the  pro- 
tection of  the  perinasum  in  a  pelvic  presentation  as  in  a  vertex, 
as  the  fore-coming  breech  rarely  or  never  distends  the  perinaeum 
sufficiently  to  cause  a  laceration.  On  the  other  hand,  the  after- 
coming  head  may  cause  considerable  laceration,  especially  in 
primiparae,  as  it  must  be  delivered  so  rapidly  that  sufficient 
time  is  not  given  for  dilatation  to  occur.  As  the  breech 
appears  at  the  vulva,  the  fingers  should  be  slipped  into  the 
vagina  beside  it  in  order  to  discover  the  position  of  the  feet.  If 
the  latter  are  lying  beside  the  breech,  each  foot  is  in  turn  guided 
out  in  order  to  prevent  them  from  catching  above  the  perinaeum, 
as  in  this  manner  a  laceration  may  be  caused.  The  breech  and 
lower  limbs  are  then  expelled  in  the  case  of  a  complete  presenta- 
tion, or  the  breech  alone  in  an  incomplete  presentation,  without 
any  further  assistance.  As  soon  as  the  umbilicus  of  the  infant 
reaches  the  vulva,  it  is  necessary  to  draw  gently  down  a  loop  of 
the  cord.  The  object  of  this  procedure  is  twofold.  In  the  first 
place,  it  is  very  important  to  have  a  reliable  guide  to  the  condition 
of  the  foetus,  inasmuch  as  we  do  not  wish  to  interfere  with  the 
natural  mechanism  of  expulsion,  unless  the  condition  of  the  foetus 
is  such  that  delivery  must  be  accelerated.  When  we  have  drawn 
down  a  loop  of  the  cord,  observation  of  the  nature  of  its  pulsa- 
tions informs  us  if  the  foetus  is  commencing  to  suffer.  In  the 
next  place,  if  the  cord  is  not  drawn  down,  there  is  a  danger  of  its 
tearing,  owing  to  the  stretching  which  it  may  undergo.  The 
body  of  the  foetus  compresses  the  cord  between  itself  and  the 
brim  of  the  pelvis,  and  tends  to  hold  it  there  ;  consequently,  as 
the  body  descends  and  increases  the  distance  between  the  umbilicus 
and  the  pelvic  brim,  there  is  no  accompanying  increase  in  the 
length  of  the  cord  between  the  umbilicus  and  the  spot  at  which  it 
is  compressed,  the  cord  becomes  progressively  tighter,  and  may 
finally  tear  away  at  the  umbilicus  owing  to  the  traction  exerted 
upon  it. 

Having  drawn  down  a  loop  of  the  cord,  no  further  interference 
is  necessary  so  long  as  its  pulsations  continue,  and  all  that  need 
be  done  is  to  support  the  body  of  the  foetus  in  its  proper  relation 


THE  MANAGEMENT  OF  PELVIC  PRESENTATION  421 

to  the  pelvis.  The  ensuing  uterine  contractions  in  a  normal  case 
expel  the  remainder  of  the  foetal  trunk  and  the  arms  folded  across 
the  chest,  and  then  drive  the  head  through  the  brim  into  the 
pelvic  cavity.  From  the  latter,  however,  it  will  almost  certainly 
require  to  be  delivered  by  artificial  means. 

If,  however,  the  cord  is  found  to  be  pulseless  when  brought 
down,  or  if  it  ceases  to  pulsate  prior  to  the  expulsion  of  the 
shoulders,  the  delivery  of  the  latter  must  be  hastened.  This  is 
the  stage  of  delivery  at  which  it  is  so  important  to  remember  the 
distinction  between  the  effects  of  pressure  applied  over  the  uterus 
and  of  traction  upon  the  body.  Pressure  acting  as  a  vis  a  tevgo 
resembles  the  uterine  contractions  and  keeps  the  arms  in  contact 
with  the  chest.  Traction  acting  as  a  vis  a  fronte  tends  to 
cause  the  arms  to  be  pushed  away  from  the  chest  by  the  pelvic 
brim  and  so  to  become  extended.  Accordingly,  if  it  is  necessary 
to  hasten  delivery,  the  first  method  to  adopt  is  firm  pressure 
over  the  fundus  of  the  uterus.  By  this  means,  in  many  cases,  the 
chest  will  be  driven  out  with  the  arms  in  their  proper  position  ; 
or,  even  if  this  does  not  occur,  it  will  be  driven  into  the  pelvic 
cavity  without  extension  of  the  arms,  and  then,  if  traction  has  to 
be  made,  the  results  are  not  so  serious  as  if  the  arms  were  still 
above  the  brim.  If,  however,  pressure  from  above  is  not  sufficient 
to  cause  the  expulsion  of  the  foetus,  we  are  compelled  to  resort  to 
traction  upon  the  body.  The  latter  is  seized  in  both  hands  by 
the  pelvis  and  drawn  downwards  as  far  as  possible.  If  the  body 
is  slippery,  as  is  frequently  the  case,  it  is  well  to  first  wrap  round 
it  a  clean  napkin  or  towel.  In  all  cases,  while  the  body  is  being 
drawn  downwards,  the  nurse  or  other  assistant  should  at  the  same 
time  make  pressure  upon  the  fundus  with  both  hands  so  placed 
that  they  encircle,  not  only  the  fundus  of  the  uterus,  but  also  the 
sides,  as  the  pressure  thus  exerted  may  be  successful  in  preventing 
the  arms  from  being  pushed  away  from  the  body.  When  the 
body  has  been  drawn  downwards  as  far  as  possible,  the  fingers 
are  passed  into  the  vagina  to  ascertain  if  the  arms  have  also 
descended.  If  they  have  done  so  they  will  be  found  in  the  vagina, 
and  can  easily  be  drawn  out  by  hooking  a  finger  into  the  bend 
of  the  elbow  and  pulling  the  latter  down.  If,  on  the  other  hand, 
they  are  not  found  in  this  position,  they  have  become  extended, 
and  must  be  brought  down  before  any  attempts  are  made  to 
deliver  the  head.  The  method  of  doing  this  will  be  described 
later  in  the  chapter  on  the  extraction  of  the  foetus  in  pelvic 
presentation. 

The  final  step  in  the  delivery  of  the  foetus  is  the  extraction  of 
the  after-coming  head.  We  have  already  pointed  out  the  frequent 
necessity  for  artificial  aid  at  this  stage,  as  the  head,  having  passed 
beyond  the  uterus,  is  not  affected  by  the  contractions  of  the  latter. 
It  is  safe  to  say  that,  if  the  head  is  not  expelled  by  the  same 
contraction  that  expels  the  shoulders,  it  must  be  extracted  by  the 
obstetrician. 


422  THE  PHYSIOLOGY  OF  LABOUR 

The  most  critical  period  of  delivery,  so  far  as  the  child  is 
concerned,  is  reached  when  the  head  has  been  expelled  from  the 
uterus  and  is  lying  in  the  pelvic  cavity.  The  latter  is  so  com- 
pletely filled  by  the  head  that  the  cord  is  almost  certainly  com- 
pressed and  circulation  through  it  checked.  The  empty  uterus  is 
commencing  to  detach  the  placenta,  so  that  even  if  the  cord  is  not 
compressed  the  danger  of  asphyxia  is  considerable.  The  cold  air 
chilling  the  body  of  the  foetus  causes  premature  attempts  at  in- 
spiration, and  consequent  inhalation  of  mucus  and  fluid  into  the 
larynx.  Consequently,  it  is  of  the  greatest  importance  that  the 
head  should  be  extracted  from  this  position  as  rapidly  as  possible. 

The  various  methods  of  effecting  the  delivery  of  the  head  will 
be  discussed  in  the  chapter  on  the  extraction  of  the  foetus  in 
pelvic  presentation. 

Prognosis. — The  maternal  prognosis  in  uncomplicated  cases  of 
pelvic  presentation  is  very  similar  to  that  in  vertex  presentation. 
Perhaps,  in  primiparae,  the  liability  to  extensive  laceration  during 
the  delivery  of  the  after-coming  head  is  greater  than  when  the 
head  comes  first.  In  cases  of  pelvic  presentation,  complicated 
with  some  other  pathological  condition,  such  as  contracted  pelvis, 
the  prognosis  is  dependent  on  the  nature  of  the  complication. 

The  foetal  prognosis,  on  the  other  hand,  is  by  no  means  as 
favourable  as  in  vertex  presentation,  on  account  of  the  danger  of 
asphyxia  during  the  passage  of  the  after-coming  head.  It  is 
extremely  difficult  to  estimate  the  average  mortality  in  these 
cases,  as  it  will  differ  to  a  marked  degree  according  to  the  skill 
and  experience  of  the  obstetrician.  Hecker  estimates  the  mortality 
at  26  per  cent.  ;  Herman*  as  at  least  1  in  10,  and  sometimes  as 
much  as  1  in  3 ;  Galabin  f  as  1  in  3  in  the  case  of  an 
extern  maternity  attended  by  students,  and  where  in  many  cases 
delivery  had  occurred  before  the  student  arrived.  At  the  Clinic 
Baudelocque,  \  on  the  other  hand,  out  of  91  children  whose 
mothers  were  primiparae  82  lived,  and  out  of  61  children  whose 
mothers  were  multiparas  53  lived ;  or,  in  all,  a  mortality  of 
about  1  in  10.  In  all  these  cases,  the  children  were  alive  at  the 
commencement  of  labour.  At  the  Rotunda  Hospital,  amongst 
435  viable  infants  born  as  pelvic  presentations,  118  were  born 
dead,  or  a  mortality  of  1  in  3-6.  It  must,  however,  be  remem- 
bered that  the  high  rate  of  mortality  in  pelvic  presentation  is  in 
part  due  to  the  fact  that  in  many  cases  the  presentation  is  the 
direct  result  of  the  antecedent  death  of  the  foetus.  Thus,  amongst 
the  118  children  who  were  born  dead  at  the  Rotunda  Hospital, 
51  were  macerated. 

Injuries  to  the  child  during  birth  are  also  of  relatively  common 
occurrence.  In  cases  of  impacted  or  obstructed  breech,  as  we 
shall  see  in  another  place,  fracture  of  the  femur  may  occur  ;  and, 
if  a  fillet  or  blunt  hook  has  been  used  to  effect  delivery,  extensive 

*  Op.  cit.,  p.  36.  f  Op.  cit.,  p.  251 

J  Ribemont  Dessaignes  and  Lepage,  op.  cit.,  p.  468. 


THE  PROGNOSIS  OF  PELVIC  PRESENTATION  423 

laceration  of  the  soft  parts  in  the  neighbourhood  of  the  groin  may 
result.  Then,  during  the  delivery  of  the  arms  fracture  ol  the 
humerus  or  clavicle  may  occur.  The  humerus  is,  as  a  rule, 
broken  by  the  direct  pressure  of  the  fingers.  The  clavicle  is 
probably  broken  by  inward  pressure  acting  through  the  head  of  the 
humerus,  and  tending  to  approximate  the  ends  of  the  bone.  Such 
a  force  may  result  either  from  the  hand  being  pushed  upwards 
between  the  side  of  the  child  and  the  pelvic  wall,  or  from  the 
pressure  of  the  pelvis  directly  on  the  head  of  the  humerus  during 
the  rotation  of  the  latter  while  the  arm  is  being  brought  down. 

Injuries  to  the  spinal  column  or  to  the  soft  parts  may  result 
from  too  violent  traction  upon  the  trunk,  and  the  ligaments  of  the 
joint  between  the  atlas  and  the  axis  vertebrae  may  be  torn  by 
forcible  rotation  of  the  body  when  the  head  is  fixed. 

Lastly,  violent  extraction  of  the  head  may  lead  to  most  severe 
injuries.  It  is  quite  possible  to  rupture  the  articulations  of  the 
cervical  vertebrae  and  to  tear  the  spinal  cord.  The  clavicles  may 
be  broken  by  the  pressure  of  the  fingers  when  applying  traction 
on  the  shoulders,  and  the  brachial  plexus  may  at  the  same  time 
be  injured  by  pressure,  with  the  result  that  temporary  paralysis 
may  be  caused  (Herman).  A  relatively  common  occurrence  is 
the  rupture  of  a  small  bloodvessel  in  the  sterno-mastoid  muscle, 
leading  to  the  formation  of  a  haematoma,  varying  in  size  from  that 
of  a  marble  to  that  of  a  pigeon's  egg,  or  a  little  larger.  Traction 
applied  on  the  floor  of  the  mouth  may  result  in  laceration  of  the 
mucous  membrane  or  tongue,  or  in  dislocation  or  fracture  of  the 
jaw. 


CHAPTER  VII 
TRANSVERSE  AND  OBLIQUE  LIES 

Frequency — ^Etiology — Positions  —  Diagnosis  —  Mechanism  —  Terminations. 
Spontaneous  Version,  Spontaneous  Evolution,  Corpore  Conduplicato  — 
Treatment,  Postural,  Cephalic  Version,  Podalic  Version — Prognosis. 

So  far,  we  have  been  alone  concerned  with  the  various  presenta 
tions  which  are  met  with  in  longitudinal  lies  of  the  fcetus,  and 


Fig.  246.— First  Shoulder  Presentation,  Back  in  Front.     (Farabceuf.) 


now  we  must  deal  with  cases  of  transverse  or  oblique  lies.  It  is, 
of  course,  obvious  that  strictly  these  cases  should  not  be  con- 
sidered under  the  physiology  of  labour,  but  inasmuch  as  it  is 

424 


THE  FREQUENCY  OF  TRANSVERSE  LIES 


425 


advantageous   to   deal  with  all    the  different  presentations  con- 
secutively, we  shall  do  so. 

As  has  been  already  mentioned,  the  actual  presentation  which 
occurs  in  a  transverse  or  oblique  lie  is  not  a  matter  of  very  great 
importance,  since  it  is  overshadowed  by  the  greater  importance 
of  the  fact  that,  no  matter  what  'part  of  the  foetus  presents,  the 
latter  cannot  be  delivered  under  otherwise  normal  circumstances. 
Consequently,  we  need  not  consider  each  possible  presentation 
separately,  but  may  group  them  all  under  the  comprehensive 
term  of  '  shoulder  presentation.'  Accordingly,  under  this  term 
we  include  all  cases  in  which  neither  the  cephalic  nor  the  podalic 
pole  of  the  foetus  presents,  and  in  which  the  long  axis  of  the 
foetus  lies  transversely  or  obliquely  in  the  uterus.     In  the  large 


Fig.  247. — First  Shoulder  Presentation,  with  the  Back  in  Front. 
The  shoulder  presenting  at  the  brim,  as  felt  by  vaginal  examination. 

majority  of  cases  one  or  other  shoulder  presents  at  the  com- 
mencement of  labour,  and  as  labour  advances  the  corresponding 
arm  is  driven  down  into  the  pelvis.  Occasionally,  however,  at 
the  commencement  of  labour,  the  actual  presentation  may  be 
part  of  the  thorax,  the  elbow  or  hand,  a  hand  or  hands,  and 
a  foot  or  feet,  or  any  part  of  the  back.  But  as  labour  advances, 
in  almost  every  case,  if  the  lie  of  the  foetus  is  not  corrected,  the 
presentation  finally  becomes  a  shoulder  presentation,  in  which  the 
corresponding  arm  has  been  driven  down  into  the  vagina.  The 
term  '  cross-birth  '  is  also  frequently  used  as  a  synonym  for  all 
cases  of  oblique  or  transverse  lies. 

Frequency. — The  relative  frequency  with  which  transverse  or 
oblique  lie  occurs  in   different  countries  differs  very   markedly. 


426 


THE  PHYSIOLOGY  OF  LABOUR 


In  Germany,  where  its  proportion  is  highest,  transverse  lie  was 
met  with  2,195  times  amongst  302,075  deliveries,  or  a  proportion  oi 
1  in  137  (Winckel).  In  France,  it  occurred  192  times  in  40,036 
cases,  or  a  proportion  of  1  in  2o8|,  according  to  various  statistics 
collected  by  Churchill,*  while,  according  to  Pinard,  it  occurs  in  a 
proportion  of  1  in  125  cases.  *In  British  practice,  according  to 
various  statistics,  also  collected  by  Churchill,  it  occurred  517  times 
in  125,670  cases,  or  a  proportion  of  about  1  in  243.  In  Guy's 
Hospital,  it  occurred  amongst  49,588  cases  in  a  proportion  of  1  in 


Fig.  248. — First  Shoulder  Presentation,  the  Back  Behind.  (Faraboeuf. ) 


354  (Galabin).  Finally,  at  the  Rotunda  Hospital,  during  the 
last  fourteen  years  it  occurred  53  times  in  19,293  cases,  or  a  pro- 
portion of  1  in  364-01.  As  the  occurrence  of  a  transverse  lie 
cannot  easily  be  overlooked,  and  as  all  these  statistics  are  based 
on  the  experience  of  well-known  authorities,  there  must  be  a 
definite  cause  for  the  marked  differences  in  frequency  which  are 
found.  The  most  obvious  explanation  which  offers  itself  is  that 
on  the  Continent  the  proportion  of  cases  of  contracted  pelvis  is 
very  much  greater  than  in  these  countries,  and  as  this  condition 
favours  the  occurrence  of  a  transverse  lie  of  the  foetus,  it  is  not 

*   '  Theory  and  Practice  of  Midwifery,'  fifth  edition,  p.  471. 


THE  CAUSES  OF  TRANSVERSE  LIES 


427 


surprising  to  find  a  higher  proportion  of  cases  abroad  than  at 
home. 

Causes.  —  We  have  seen  that  the  common  cause  of  mal- 
presentation  is  loss  or  alteration  of  the  normal  relation  which 
exists  between  the  shape  of  the  foetus  and  the  shape  of  the 
uterine  cavity.  So  long  as  this  loss  or  alteration  is  not  too  great, 
a  longitudinal  lie  of  the  foetus  will  still  occur,  although  the  pelvic 
pole  may  occupy  the  lower  uterine  segment  instead  of  the  fundus. 
If,  however,  the  alteration  is  so  marked  that  the  uterine  wall  no 
longer  exercises  a  restraining  effect  on  the  lie  of  the  foetus,  then 
transverse  or  oblique  lies  become  relatively  common.  Accord- 
ingly, in  enumerating  the  various  conditions  which   favour  the 


Fig.   249. — First  Shoulder  Presentation,  with  the  Back  Behind. 
The  shoulder  presenting  at  the  brim,  as  felt  by  vaginal  examination. 


occurrence  of  this  lie,  we  must  expect  to  obtain  a  list  very  similar 
to  that  given  in  the  case  of  pelvic  presentation,  inasmuch  as  it  is 
to  a  difference  in  the  degree  of  the  condition  present,  rather  than 
in  the  actual  condition  itself,  that  «the  occurrence  of  a  pelvic 
presentation  in  one  case  and  of  a  shoulder  presentation  in  another 
case  is  due.  The  principal  causes  of  transverse  or  oblique  pre- 
sentation are  as  follows  : — 

Contracted  Pelvis. — Michaelis*  met  with  shoulder  presenta- 
tion in  i-2  per  cent,  of  patients  in  whom  the  pelvis  was  normal, 
while  in  patients  in  whom  the  pelvis  was  contracted  he  found  the 
same  presentation  in  5*4  per  cent,  of  cases. 

Tumours  of  the  Uterus.  —  In   195  cases  of   myomata  of   the 

*  '  Das  enge  Becken,'  p.  183. 


428 


THE  PHYSIOLOGY  OF  LABOUR 


uterus,  shoulder  presentation  occurred  twenty-two  times — i.e.,  in 
about  1 1  *3  per  cent." 

Multiparity.  —  The  greater  the  number  of  children  a  woman 
has  borne,  the  more  lax  becomes  the  uterine  wall,  and  the  less 
the  controlling  pressure  exerted  upon  the  foetus.  According  to 
Winckel,!  shoulder  presentation  occurs  four  times  more  fre- 
quently in  multipara?  than  in  primiparae,  and  eight  times  more 
frequently  in  pluriparse  than  in  multiparae. 

Multiple  Pregnancy. — An  oblique  presentation  is  said  to  occur 
in  cases  of  twins  in  a  proportion  of  i  in   15*7,  and  to  be  more 


Fig.  250. 


-Second  Shoulder  Presentation,  the  Back  in  Front. 
(Farabceuf. ) 


common  in  the  case  of  the  second  twin  (Winckel).  This  is  but 
natural,  as  the  controlling  effect  of  the  pressure  of  the  uterine 
wall  on  the  second  twin  is  very  slight. 

Hydramnios. — This  condition  has  been  found  in  10  per  cent, 
of  cases  of  shoulder  presentation  (Winckel),  whereas  the  usual 
proportion  of  cases  in  which  it  occurs  is  about  1  in  200. 

Premature   Children. — According   to    Simpson,}    oblique   pre- 


*  Susserot,  I.  D.,  Rostock,  p.  8,  21,  fig.  48;  and  Toloczinow,  Wiener  med. 
Presse,  1868,  Nr.  30. 
■\  Op.  cit.,  p.  402. 
J   '  Obstetric  Memoirs,'  edited  by  Priestley,  vol.  ii.,  1856,  p.  138. 


THE  CAUSES  OF  TRANSVERSE  LIES 


429 


sentations  are  met  with  in  the  case  of  premature  children  ten 
times  more  frequently  than  in  the  case  of  full-term  children. 

Macerated  Foetus. — According  to  various  statistics  collected 
by  Winckel,  the  foetus  is  macerated  in  12-2  per  cent,  of  cases  of 
shoulder  presentation. 

Malformations  of  the  Uterus.  —  Cases  have  been  recorded 
in  which  repeated  shoulder  presentation  has  occurred  in  associa- 
tion with  such  malformations  of  the  uterus  as  uterus  bicornis  and 
uterus  septus,  so  clearly  proving  a  causal  relationship. 

Malformations  of  the  Fcetus. — Monstrosities,  tumours,  cystic 
conditions  of  the  foetal  organs,  collections  of  fluid  in  the  thorax  or 


Fig.  251. — Second  Shoulder  Presentation,  with  the  Back  in  Front. 
The  shoulder  presenting  at  the  brim,  as  felt  by  vaginal  examination. 


peritoneal  cavity,  all  favour  the  occurrence  of  shoulder  presenta- 
tion in  accordance  with  their  site  and  the  effect  they  produce 
on  the  shape  of  the  fcetus. 

Obliquity  of  the  Uterus.  —  This  condition,  especially  when 
in  association  with  a  large  and  lax  uterus,  is  prone  to  cause 
oblique  lies  of  the  foetus. 

Placenta  Praevia. — Simpson  found  15  cases  of  placenta  prsevia 
amongst  366  cases  of  shoulder  presentation — a  proportion  of  about 
1  in  24.  The  ordinary  proportion  of  cases  in  which  placenta 
praevia  occurs  is  1  in  200  to  300. 

The  foregoing  are  the  more  common  causes  of  transverse  or 
oblique  lie  of  the  foetus.  There  are  also  rarer  causes.  Extreme 
shortness  of  the  umbilical  cord  has  been  noticed  in  a  few  cases,  as 
have  ovarian  tumours  and  prolapse  of  a  hand  alongside  the  head. 


43° 


THE  PHYSIOLOGY  OF  LABOUR 


A  curious  and  so  far  unexplained  fact  is  to  be  found  in  the  very 
much  larger  proportion  of  male  than  female  infants  that  are  met 
in  transverse  or  oblique  lies.  Thus,  Winckel  found  amongst 
282  cases  of  these  lies  192  male  and  90  female  infants,  whereas 
the  usual  proportion  of  male  to  female  infants  is  as  17  is  to  16. 

Positions. — It  is  not  possible  in  transverse  or  oblique  lies  of  the 
foetus  to  adopt  a  similar  classification  of  positions  to  that  adopted 
in  longitudinal  lies,  as  the  relation  of  the  back  to  the  middle  line 
is  so  very  different.     Several  different  classifications  have  been 


Fig.  252. 


-Second  Shoulder  Presentation,  the  Back  Behind. 
(Faraboeuf. ) 


proposed  from  time  to  time,  and  of  them  perhaps  the  best,  and 
the  one  most  nearly  in  keeping  with  the  system  of  classification 
which  we  have  so  far  adopted,  is  that  proposed  by  Hohle,*  who 
recognises  two  positions,  according  to  the  side  of  the  mother  to 
which  the  head  of  the  foetus  is  turned,  and  subdivides  them  into 
two  more  according  as  the  back  is  directed  in  front  or  behind. 

Those  who  adopt  Naegele's  classification  of  positions  in 
longitudinal  lies  may,  however,  consider  the  classification  of 
Winckel  more  suitable  in  the  present  case,  as  the  latter  recognises 
four  positions,  and  numbers  them  in  order  of  frequency.  The 
two  classifications  may  be  tabulated  thus  : — 

*  Lehrb.,  II.  Aufl.,  588. 


THE  DIAGNOSIS  OF  TRANSVERSE  LIES 
First  position,   head  to  thef  Back  in  front  (first  position  of  Winckel) . 

[Back  behind  (fourth  position  of  Winckel). 

0  j  ,        ,  .     ..      (Back  in  front  (second  position  of  Winckel). 

Second  position,  head  to  the  |  v  r  ; 


43> 


jht. 


Back  behind  (third  position  of  Winckel). 


From  the  statistics  of  894  cases  of  transverse  or  oblique  lie 
collected  by  Winckel,  it  appears  that  the  number  of  cases  in 
which  the  back  lies  in  front  is  to  the  number  in  which  it  lies 
behind  as  i\  is  to  1,  while  the  head  is  almost  equally  frequently 
directed  to  the  left  or  to  the  right. 

Diagnosis. — The  diagnosis  of  transverse  or  oblique  lies  can  be 


Fig.  253. — Second  Shoulder  Presentation,  with  the  Back  Behind. 
The  shoulder  presenting  at  the  brim,  as  felt  by  vaginal  examination. 


made   by   abdominal    palpation    and   vaginal    examination,    and 
perhaps  occasionally  by  auscultation. 

Abdominal  Palpation. — If  the  lie  is  transverse,  neither  pole  of 
the  foetus  will  be  found  at  the  fundus.  If  the  lie  is  oblique,  one 
or  other  pole  may  be  found  displaced  into  one  or  other  hypo- 
chondrium.  Then,  on  carrying  the  hand  lower  down,  the  opposite 
pole  is  found  in  the  opposite  iliac  region.  If  the  back  is  anterior, 
it  is  readily  felt  as  a  firm  and  resisting  mass  connecting  the 
two  poles.  If  it  is  posterior,  the  limbs  are  felt  with  consider- 
able distinctness  pressed  against  the  abdominal  wall.  If  labour 
has  only  recently  commenced,  the  pelvic  brim  is  found  to  be 
empty,  and  the  outline  of  a  shoulder  may  be  made  out  lying  near 
the  brim.  If  labour  has  been  in  progress  for  some  time,  and 
the  presenting  part  has  been   driven  into  the  brim,  it   will    be 


432  THE  PHYSIOLOGY  OF  LABOUR 

difficult  to  determine  the  exact  nature  of  the  part  on  account  of 
the  manner  in  which  the  fcetal  trunk  is  compressed,  but  in  most 
cases  there  will  even  then  be  no  difficulty  in  detecting  the 
presence  of  the  head  in  the  false  pelvis. 

Vaginal  Examination. — At  the  commencement  of  labour,  it  is 
usually  impossible  to  reach  the  presenting  part,  unless  the  entire 
hand  is  passed  into  the  vagina.  As,  however,  the  presenting  part 
is  driven  down  into  the  brim,  it  can  be  readily  reached  and  its 
nature  determined.     At  first,  it  is  most  usual  to  find  a  shoulder 


Fig.   254.— Diagram  representing  the  Fcetus  as  felt  by  Abdominal 

Palpation  in  Shoulder  Presentation. 

The  shaded  portions  of  the  foetus  are  those  that  are  felt  most  distinctly. 

presenting,  or  perhaps  some  part  of  the  thorax.  Later,  an 
arm  usually  prolapses,  and  can  be  recognised  and  distinguished 
from  a  leg  in  the  manner  which  has  been  already  described. 
It  is  easy  to  determine  to  which  side  the  arm  belongs  if  we 
imagine  ourselves  shaking  hands  with  it.  If  the  thumb  of  the 
examining  hand  lies  in  contact  with  the  thumb  of  the  prolapsed 
hand,  the  palms  being  in  imaginary  contact,  the  prolapsed  hand 
must  be  right  or  left,  according  as  the  examining  hand  is  right  or 
left.  A  careful  examination  must  also  be  made  in  these  cases  to 
determine  whether  the  umbilical  cord  is    lying  over  or  in  the 


SPONTANEOUS   VERSION  453 

uterine  orifice,  as  prolapse  or  presentation  of  the  cord  is  relatively 
very  common. 

Auscultation. — Auscultation  as  a  means  of  diagnosis  in  shoulder 
presentation  is  not  of  any  great  value,  as  there  is  nothing 
very  characteristic  in  the  position  in  which  the  heart  is  heard. 
If  the  back  lies  in  front  and  labour  has  not  progressed  far,  the 
heart  is  heard  in  or  close  to  the  middle  line  and  nearer  to  the 
symphysis  than  is  usual  at  this  stage  of  labour.  If  the  shoulder 
has  descended  into  the  pelvis  it  may  be  impossible  to  hear  the 
heart  at  all,  even  though  the  foetus  is  alive.  If  the  back  is 
posterior,  it  may  be  also  impossible  to  hear  the  heart  on  account 
of  the  depth  below  the  surface  at  which  it  lies. 

Mechanism. — There  is  no  mechanism  in  the  ordinary  sense  of 
the  word  in  a  shoulder  presentation,  for  the  obvious  reason  that, 
save  in  rare  cases  and  under  certain  conditions,  the  expulsion  of 
the  foetus  is  impossible.  The  course  that  labour  pursues  is  that 
a  shoulder  is  driven  down  into  the  pelvis  and  the  corresponding 
arm  prolapses.  As  labour  continues,  the  shoulder  is  driven 
down  still  more  deeply,  until  its  further  advance  is  checked  bv 
the  size  of  the  diameters  which  are  brought  into  the  brim. 
Then,  if  the  case  remains  untreated,  the  foetus  dies,  and  if  the 
uterine  contractions  continue  the  uterus  ruptures.  If  the  contrac- 
tions cease,  the  foetus  commences  to  decompose  and  the  mother 
dies  of  exhaustion  and  septic  absorption.  Although  there  is  no 
mechanism  in  the  case  of  transverse  presentations,  there  are  certain 
terminations  which  may  occur  and  result  in  delivery,  but  though 
these  terminations  are  the  result  of  the  natural  efforts,  they  must 
in  no  way  be  considered  to  be  natural  terminations  ;  on  the  con- 
trary, they  are  quite  unnatural  and  exceptional. 

Terminations. — These  terminations  are  as  follows  : — Spontaneous 
version  ;  spontaneous  evolution  ;  and  birth  corpore  conduplkato . 

Spontaneous  Version. — This  is  the  term  applied  to  the  correction 
of  the  lie  of  the  foetus  by  the  contractions  of  the  uterus,  and 
results  in  the  presentation  of  either  the  cephalic  or  pelvic  pole. 
It  is  especially  likely  to  occur  in  oblique  lies,  and  can  in  some 
cases  be  brought  about  by  placing  the  patient  in  a  suitable 
position,  as  will  presently  be  described.  Spontaneous  version 
may  occur  either  before  or  after  rupture  of  the  membranes. 
When  the  resultant  presentation  is  pelvic,  version  usually  takes 
place  after  the  membranes  have  ruptured,  when  cephalic,  before 
the  membranes  have  ruptured.  In  cases  in  which  a  pelvic 
presentation  results,  a  foot  or  knee  presentation  is  the  usual 
variety,  owing  to  the  fact  that  in  an  oblique  lie  of  the  foetus  with 
the  pelvic  pole  lowest  the  feet  may  be  found  immediately  over 
the  internal  os,  and  so  may  be  the  first  part  driven  down  after 
the  membranes  have  ruptured.  Several  English  writers,  notably 
Herman  and  Galabin,  limit  the  term  '  spontaneous  version '  to 
cases  in  which  a  shoulder  presentation  is  converted  into  a  pelvic 
presentation,  while  they  term  its  conversion  into  a  cephalic  pre- 

28 


434  THE  PHYSIOLOGY  OF  LABOUR 

sentation  '  spontaneous  rectification.'  This  appears  to  us  to 
be  a  needless  multiplication  of  terms,  inasmuch  as  in  ordinary 
obstetrical  nomenclature  the  correction  of  the  lie  of  the  foetus, 
or  the  substitution  of  one  pole  for  the  other,  is  termed  'version.' 
If  we  here  adopt  the  term  'rectification'  we  should,  in  order  to  be 
consistent,  also  substitute  it  for  the  term  '  cephalic  version  '  in 
all  other  cases.  The  manner  in  which  spontaneous  version 
occurs  prior  to  the  rupture  of  the  membranes  is  not  difficult 
to  understand.  Before  labour,  the  uncontracted  uterus  allowed 
the  foetus  to  lie  in  such  a  position  that  its  long  diameters  did  not 
correspond  with  the  long  diameters  of  the  uterus,  but,  as  soon  as 
contractions  occur,  the  pressure  of  the  uterine  wall  tends  to  guide 
the  foetus  round  into  a  longitudinal  lie.  If  the  patient  is  placed  in 
such  a  position  that  the  action  of  gravity  on  the  foetus  facilitates 
this  change,  the  latter  occurs  prior  to  rupture  of  the  membranes 
with  comparative  frequency  in  oblique  lies.  The  manner  in  which 
a  shoulder  presentation  sometimes  becomes  converted  into  a  pelvic 
presentation  after  the  rupture  of  the  membranes  is  more  difficult  to 
explain.  The  process  was  first  described  by  Denman*  under  the 
term  '  spontaneous  evolution,'  but  this  term  is  incorrect  and  more 
properly  applied  to  a  quite  different  phenomenon.  Denman's 
explanation  of  the  manner  in  which  the  change  of  presentation 
occurs,  put  shortly,  was  that  the  body  in  its  doubled  state  being  too 
large  to  pass  into  the  pelvis,  the  contractions  of  the  uterus,  acting 
principally  upon  the  pelvic  pole,  which  is  the  only  part  free  to 
move,  drive  the  latter  downwards,  while  at  the  same  time  the 
cephalic  pole  is  crowded  upwards  farther  away  from  the  brim. 
If  this  movement  is  continued,  it  is  possible  to  imagine  that  at  a 
certain  stage  the  pelvic  pole  will  come  to  lie  a  little  lower  than 
the  cephalic  pole,  and  that  once  this  happens  there  will  be  a 
tendency  for  the  latter  to  ascend  to  the  fundus,  leaving  the  former 
free  to  descend  into  the  brim.  It  is,  however,  a  most  difficult 
process  to  explain,  and  occurs  in  so  few  cases  that  in  practice 
it  must  not  be  taken  into  consideration. 

Spontaneous  Evolution. — This  peculiar  process  was  first  de- 
scribed by  Douglas!  of  Dublin.  Its  nature  will  be  best  understood 
by  reference  to  the  accompanying  diagrams  (v.  Figs.  255,  256). 
The  shoulder  is  driven  down  into  the  pelvis  and  the  corre- 
sponding arm  prolapses.  The  corresponding  clavicle  and  the 
side  of  the  neck  is  fixed  behind  the  symphysis,  and  the  back, 
acutely  flexed,  is  driven  downwards  and  appears  at  the  vulva. 
The  remainder  of  the  trunk  is  then  driven  down,  the  angle  of 
flexion  of  the  spine  moving  gradually  downwards  along  the  spine 
towards  the  breech,  until,  finally,  the  breech  and  lower  limbs  are 
born.  All  this  time  the  remaining  arm  and  shoulder  and  the 
head  are  still  above  the  brim,  and  the  final  act  consists  in  their 

*  '  Introduction  to  the  Practice  of  Midwifery,'  seventh  edition,  p.  355. 
f  '  Explanation  of  the  Real  Process  of  the  Spontaneous  Evolution,'  etc., 
second  edition.     Dublin,  1819. 


BIRTH  'CORPORE  CONDUPLICATO 


435 


expulsion  as  in  a  pelvic  presentation.  It  will  thus  be  seen  that 
the  entire  body  revolves  round  the  shoulder,  which  is  jammed 
against  the  symphysis.  It  will  readily  be  understood  that  this 
mechanism  can  only  take  place  in  a  small  and  very  soft  foetus, 


Fig.  255. — Spontaneous  Evolution  of  the  Foztus  in  Shoulder 
Presentation. 

A,  First  step  ;  B,  second  step. 

and  its  occurrence  has  rarely  been  noted  save  in  one  which 
was  premature  and  macerated.  Still,  cases  have  been  recorded 
in  which  the  foetus  was  not  only  born  alive,  but  subsequently 
lived.        Under  any   circumstances   spontaneous   evolution  is  a 


Fig.  256. —Spontaneous  Evolution  of  the  Fcetus  in  Shoulder 
Presentation. 

C,  Third  step  ;   D,  fourth  step. 

phenomenon  of  great  rarity,  and  the  possibility  of  its  occurrence 
must  never  be  taken  into  consideration  in  the  management  of 
a  case. 

Birth  '  Corpore  Conduplicato.' — Birth  corpore  conduplicato,  or  spon- 
taneous expulsion  as  it  is  sometimes  termed,  was  first  described 
by  Kleinwachter.*     The  first  stage  in  this  process  is  similar  to 


Arch.  f.  Gyn.,  B.  II.,  p.  in. 


28—2 


436  THE  PHYSIOLOGY  OF  LABOUR 

that  of  spontaneous  evolution.  The  shoulder  is  driven  down 
into  the  pelvis,  the  arm  prolapses,  and  the  back,  acutely  flexed, 
appears  at  the  vulva.  Then,  the  head,  the  second  arm,  and  the 
breech  closely  compressed  descend  together  through  the  pelvis 
and  are  born,  the  lower  limbs  being  the  last  to  appear.  Such 
a  process  necessitates  a  smaller  and  softer  foetus  than  even  spon- 
taneous evolution,  and  it  never  occurs  save  in  a  dead  and 
macerated  foetus. 

Management. — In  all  cases  in  which  it  is  possible  a  transverse  or 
oblique  lie  of  the  foetus  must  be  changed  into  a  longitudinal  lie, 
and  if  it  is  impossible  to  do  so,  embryotomy  must  be  performed. 
There  are  three  principal  methods  by  which  the  lie  of  the  foetus 
can  be  corrected,  and  the  method  of  choice  is  always  that  by 
which  the  correction  can  be  effected  with  the  least  possible 
amount    of  manipulation    and    by  external    manipulation  rather 


Fig.  257. — The  Moulding  of  the  Fcetus  that  occurs  during  Birth 
'corpore  conduplicato.' 

(From  a  photograph  of  a  case  at  the  Rotunda  Hospital.) 

than  internal.     The  three  methods  of  correction  are  as  follows  : — 
Postural  treatment ;  cephalic  version  ;  and  podalic  version. 

Postural  Treatment. — Postural  treatment  consists  in  placing 
the  patient  in  such  a  position  that  the  action  of  gravity  brings 
the  foetus  into  a  longitudinal  lie.  As  has  been  already  said,  it 
is  merely  a  means  of  increasing  the  tendency  to  the  occurrence 
of  spontaneous  version.  In  order  that  it  may  be  successful  the 
membranes  must  be  intact,  so  that  the  foetus  is  free  to  move 
in  the  uterine  cavity,  and  the  presenting  part  must  be  above  the 
brim.  When  the  patient  lies  upon  one  side,  the  fundus  of  the 
uterus  falls  over  to  that  side,  carrying  with  it  one  pole  of  the  foetus 
and  tending  to  cause  a  corresponding  deviation  of  the  other  pole 
towards  the  opposite  side  (v.  Fig.  258).  Accordingly,  in  carrying 
out  the  postural  treatment,  the  patient  lies,  during  the  first  stage, 
upon  the  side  at  which  is  found  the  lower  pole  of  the  fcetus. 
In  a  favourable  case  this  pole  is  as  a  result  carried  over  the  pelvic 
brim,  where  it  will  be  felt  by  abdominal  palpation.  If  this 
occurs,  nothing  further  need  be  done  until  the  uterine  orifice  is 


THE  MANAGEMENT  OF  TRANSVERSE  LIES 


437 


almost  dilated,  when  the  membranes  may  be  ruptured  in  order 
to  allow  the  presenting  pole  to  descend  and  become  fixed.  If, 
however,  the  necessary  correction  does  not  take  place,  another 
line  of  treatment  must  be  adopted. 

Cephalic  Version. — Cephalic  version  is  performed  by  external 
manipulations  in  the  manner  which  will  be  described  when  dis- 
cussing obstetrical  operations,  and  requires  the  same  conditions 
as  the  postural  treatment  for  its  successful  performance.  To 
maintain  the  foetus,  so  far  as  possible,  in  its  new  position,  a  tight 


Fig.  258. — Diagram  showing  the  Effects  of  Posture  on  a  Shoulder 

Presentation. 

When  the  patient  lies  on  her  left  side,  the  uterus  moves  as  shown  by  the 
arrows  until  it  occupies  the  position  shown  by  the  dotted  outline.     (Bumm.) 

abdominal  binder  must  be  applied  and  the  membranes  ruptured 
as  soon  as  the  uterine  orifice  is  half  dilated.  As  the  prognosis 
for  the  infant  is  better  when  the  cephalic  pole  presents,  cephalic 
version  is  preferable  to  podalic,  but  it  is  not  always  possible  to 
successfully  perform  it.  Further,  even  when  it  is  successfully 
performed,  it  is  not  always  possible  to  maintain  the  foetus  in  its 
new  presentation.  If  the  transverse  lie  recurs,  or  if  the  head  will 
not  fix,  we  must  resort  to  the  third  method  of  correction. 

Podalic  Version. — Podalic  version  is  indicated  in  all  cases  of 


438  THE  PHYSIOLOGY  OF  LABOUR 

transverse  or  oblique  lie  in  which  the  foregoing  methods  of  correc- 
tion are  impossible  or  have  proved  unsuccessful,  save  in  cases  in 
which  labour  has  already  continued  for  so  long  that  there  would 
be  a  danger  of  rupturing  the  uterus  while  performing  the  neces- 
sary manipulations.  It  is  performed  by  the  bi-polar  or  the  internal 
method,  according  as  the  os  is  sufficiently  dilated  to  admit  only 
a  couple  of  fingers  or  the  entire  hand.  In  all  cases,  one  foot  is 
drawn  down  into  the  vagina,  as  by  this  means  a  recurrence  of  the 
transverse  lie  is  prevented.  As  soon  as  this  has  been  done,  the 
remainder  of  the  expulsion  of  the  foetus  should  be  left  to  the 
natural  efforts,  unless  the  condition  of  the  mother  or  the  foetus 
is  such  as  to  call  for  immediate  delivery. 

If  podalic  version  is  impossible  or  contra-indicated,  or  if  its 
performance  is  difficult  and  the  foetus  is  dead,  then  embryotomy 
must  be  performed  and  the  foetus  extracted.  The  usual  form  of 
embryotomy  adopted  in  these  cases  is  decapitation,  as  the  neck  is, 
as  a  rule,  within  easy  reach.  When  the  neck  has  been  cut  through, 
the  body  can  be  delivered  by  pulling  down  the  arms  and  then 
applying  traction  to  them.  The  detached  head  is  delivered 
last.  If  the  neck  cannot  be  reached,  evisceration  is  performed 
instead.  A.  R.  Simpson  recommends  the  performance  of  spondy- 
lotomy, or  division  of  the  vertebral  column,  as  a  substitute  for 
decapitation.  If,  however,  the  neck  can  be  reached,  the  latter 
operation  is,  we  consider,  more  suitable,  but,  as  an  adjunct  to 
evisceration  in  cases  where  the  neck  cannot  be  reached,  spondy- 
lotomy is  useful. 

Prognosis. — The  prognosis  for  the  foetus  is  always  serious  in 
transverse  lie,  both  on  account  of  the  pathological  condition  which 
causes  the  malpresentation,  and  on  account  of  the  dangers  to 
which  the  foetus  is  exposed  during  the  correction  of  the  latter.  The 
prognosis  to  a  great  extent  depends  upon  the  period  of  labour  at 
which  the  patient  first  comes  under  treatment.  If  the  case  is  seen 
sufficiently  early,  there  is  no  reason  that  the  life  of  the  child 
should  not  be  saved.  If,  however,  it  is  not  seen  until  late  in 
labour,  the  foetus  is  often  already  dead.  Winckel  places  the  foetal 
mortality  in  cases  in  which  the  foetus  was  alive  at  the  commence- 
ment of  labour  at  33  per  cent.  At  Guy's  Hospital  70  per  cent, 
of  the  children  were  stillborn,  but  many  of  these  were  dead  at  the 
commencement  of  labour.  In  the  Rotunda  Hospital,  amongst 
35  cases  of  transverse  or  oblique  lie,  13  children  were  stillborn, 
a  proportion  of  1  in  27. 

The  maternal  prognosis  is  also  more  serious  than  in  the  other 
presentations.  Winckel  places  the  mortality  at  about  5*5  per 
cent.  At  the  Rotunda  Hospital,  on  the  other  hand,  in  the  cases 
already  alluded  to,  all  the  mothers  recovered. 


PART    V 
THE  PHYSIOLOGY  OF  THE  PUERPERIUM 


Plate  V.— Mesial  Sagittal  Section  of  a  Woman  who  died  Five  Minutes 
after  Delivery.     (Webster.) 

[To  face  ft.  441. 


CHAPTER  I 
THE  PHENOMENA  OF  THE  PUERPERIUM 

Changes  in  the  Genital  Tract :  Changes  in  the  Uterus,  in  the  Appendages  and 
Ligaments,  in  the  Vagina,  in  the  Perinseum  and  Pelvic  Floor — Changes 
in  the  Breasts— The  Composition  of  Milk — Changes  in  the  Organism  in 
General,  in  the  Circulatory  System,  in  the  Temperature,  in  the  Urinary 
System,  in  the  Digestive  System,  in  the  Respiratory  System  and  Skin,  in 
the  Abdominal  Walls,  in  the  Pelvic  Joints —Symptoms — Diagnosis. 

The  puerperium,  or  the  puerperal  state,  is  the  term  applied  to  the 
period  during  which  the  woman  is  recovering  from  the  effects  of 
pregnancy  and  parturition.  Strictly  speaking,  it  lasts  from  the 
completion  of  the  third  stage  until  the  completion  of  uterine 
involution — that  is,  for  about  six  weeks,  but,  clinically,  it  is 
considered  to  end  as  soon  as  the  lochial  discharge  has  ceased — 
that  is  to  say,  about  the  tenth  or  twelfth  day.  During  this  period 
the  maternal  organism  is  recovering  from  the  changes  which 
occurred  in  it  as  a  result  of  pregnancy  and  labour,  and  the  future 
welfare  of  the  woman  demands  that  this  process  of  repair  should 
be  carried  out  in  a  normal  manner  and  should  be  complete. 
Accordingly,  it  is  necessary  to  carefully  study  the  phenomena  of 
the  normal  puerperium. 

The  phenomena  of  the  puerperium  may  be  divided  into  three 
groups : — 

(i)  Changes  in  the  genital  tract. 

(2)  Changes  in  the  breasts. 

(3)  Changes  in  the  organism  in  general. 

Changes  in  the  Genital  Tract. 

As  the  changes  which  occur  in  the  genital  tract  are  of  necessity 
very  considerable,  they  will  be  considered  under  different  heads. 

Changes  in  the  Uterus. — The  changes  which  occur  in  the  uterus 
are  included  in  the  term  'involution  of  the  uterus.'  Immediately 
after  the  completion  of  labour  the  uterus  may  be  considered  as 
consisting  of  two  parts,  the  upper  uterine  segment  and  the  lower 
uterine  segment  and  cervix.  The  upper  segment  includes  all  that 
lies  above  the  retraction  ring,  and  is  firm  and  more  or  less  globular 
in  outline.     The  lower  segment  and  cervix  include  all  that  lies 

441 


442  THE  PHYSIOLOGY  OF  THE  PUERPERIUM 

below  the  retraction  ring,  and  is  soft,  flabby,  and  shapeless.  The 
cervical  portion  is  thicker  than  the  lower  uterine  segment,  but  it 
it  impossible  to  exactly  determine  their  junction.  The  fundus  of  the 
uterus  reaches  to  the  umbilicus,  or  perhaps  a  little  higher,  and  the 
walls  of  the  upper  segment  are  about  one  and  a  half  inches  in  thick- 
ness. On  examining  the  inner  surface,  two  areas,  differing  con- 
siderably in  appearance,  can  be  distinguished.  The  first  of  these 
is  the  placental  site,  and  the  second  the  remainder  of  the  uterine 
cavity.  The  placental  site  is  oval  in  form,  measures  about  four 
inches  by  three  inches,  and  is  represented  by  a  slightly  raised 
surface  of  irregular  elevations  and  depressions,  due  to  the  adherent 
remains  of  the  spongy  portion  of  the  decidua  serotina.  It  is 
usually  covered  by  clots,  which  pass  into  the  mouths  of  the 
vessels,  and  if  the  clots  are  gently  removed  the  latter  become 
visible.  The  remainder  of  the  uterine  cavity  is  smooth,  save 
where  small  elevations  formed  by  fragments  of  decidua  project. 
The  junction  between  the  upper  and  lower  segments  is  easily 
distinguished,  owing  to  the  sudden  change  from  the  thick  and 
firm  walls  of  the  former  to  the  thin  and  flaccid  walls  of  the  latter. 
The  lower  segment  and  cervix  are  congested  and  cedematous 
owing  to  their  relaxed  condition,  and  so  contrast  with  the  some- 
what anaemic  condition  of  the  remainder  of  the  uterus.  Their 
surface  is  similar  to  that  of  the  upper  segment,  save  that  no  decidua 
is  found  in  the  cervix.  The  junction  between  the  two — i.e.,  the 
internal  os — can  scarcely  be  detected,  so  completely  has  the  cervical 
cavity  become  incorporated  with  the  lower  uterine  segment.  At 
the  end  of  about  six  weeks,  when  involution  is  ended,  the  uterus 
has  returned  almost  completely  to  its  non-impregnated  condition, 
and  only  differs  from  a  virginal  uterus  in  that  it  is  slightly  larger, 
its  tissues  more  rigid,  the  body  a  little  more  globular,  the  cervix 
shorter  in  comparison  with  the  length  of  the  body,  and  the  os 
externum  transverse  instead  of  circular,  and  perhaps  enlarged  by 
lacerations  of  the  cervical  tissue.  The  changes  which  occur 
during  involution  in  the  various  structures  of  which  the  uterus 
is  composed  are  as  follows  : — 

The  Peritoneum. — The  peritoneal  covering  of  the  uterus,  which 
was  at  first  wrinkled,  owing  to  the  smaller  extent  of  surface  to 
which  it  had  to  adapt  itself  after  the  emptying  of  the  uterus, 
gradually  returns  to  its  normal  condition  as  the  temporary 
hypertrophy  of  pregnancy  disappears. 

The  Uterine  Muscle. — The  changes  which  take  place  in  the 
uterine  muscle  are  well  marked  and  considerable.  Their  exact 
nature  cannot  be  regarded  as  having  been  definitely  settled,  but 
they  are  in  great  part,  or  altogether,  due  to  the  deprivation  of 
blood,  resulting  from  the  obliteration  of  many  of  the  vessels  in 
the  uterine  wall  by  retraction,  and  possibly  by  the  compression 
of  the  supplying  vessels  external  to  the  uterus  by  the  weight  of 
the  latter  (Webster").  The  large  muscle  fibres  which  are  found 
*   '  Text-book  of  Obstetrics,'  p.  256,  1903. 


THE  INVOLUTION  OF  THE  UTERUS  443 

in  pregnancy  disappear,  and  in  their  place  is  found  the  ordinary 
unstriped  fibre  of  the  unimpregnated  uterus.  According  to  many 
authorities  (Winckel,  Kolliker),  some  of  the  fibres  undergo  a 
fatty  degeneration  and  disappear,  whilst  others  atrophy  but 
persist  as  smaller  fibres.  This  explanation,  which  used  to  be 
more  or  less  universally  held  to  be  correct,  has  of  recent  years 
been  disputed.  Helme,"  who  has  investigated  the  changes  in 
rabbits,  states  that  fatty  degeneration  of  the  muscle  never  occurs, 
but  that  the  process  is  one  of  atrophy,  which  results  in  a  diminu- 
tion in  the  bulk  of  the  fibres,  probably  by  a  process  of  solution. 
He  further  believes  that  there  is  no  production  of  new  fibres,  as 
there  is  no  karyokinesis.  This  tends  to  support  a  former  view 
expressed  by  Fischer,!  who  considered  that  the  alteration  in  size 
of  the  uterus  was  due  to  the  conversion  of  the  muscle  albumin 
into  a  soluble  modification  such  as  peptone,  which  was  then  in 
part  excreted  from  the  blood  by  the  kidneys,  and  in  part  carried 
away  in  the  lochia.  It  is  also  probable  that  some  of  the  products 
of  solution  are  carried  away  in  the  lymph  stream.  According  to 
Spiegelberg  and  others,  new  muscle  fibres  are  developed  from  the 
embryonic  cells  in  the  connective  tissue,  but  this  is  at  variance 
with  the  observations  of  Helme.  Sanger,  on  the  other  hand, 
after  careful  examination,  determined  the  presence  of  fatty 
degeneration  affecting  a  portion  of  the  protoplasm,  but  nowhere 
was  he  able  to  find  any  fatty  detritus  outside  the  muscle  fibre. 
He  believes  that  the  important  changes  in  the  fibres  are  due  to 
a  hyaline  and  finely  granular  degeneration,  and  that,  while  there 
may  be  slight  fatty  degeneration  as  well,  when  it  is  extensive  it 
is  pathological.  He  further  considers  that  the  products  of  de- 
generation are  for  the  most  part  oxidized  where  they  are,  and  do 
not  find  their  way  into  the  maternal  blood.  On  the  whole, 
Helme's  view  is  probably  the  one  most  likely  in  the  present  state 
of  our  knowledge  to  be  correct. 

The  Mucous  Membrane. — The  changes  which  occur  in  the  uterine 
mucosa  result  in  the  disappearance  of  the  remains  of  decidua  left 
behind  after  delivery,  and  in  the  regeneration  of  the  normal  mucous 
membrane.  As  has  been  mentioned,  a  considerable  amount  of 
the  spongy  portion  of  the  decidua  serotina  remains  adherent  to 
the  placental  site,  while  the  rest  of  the  uterus  is  irregularly  covered 
by  the  remains  of  the  deeper  layers  of  the  decidua  vera.  This 
•layer  contains  fragments  of  glands,  in  the  deeper  parts  of  which 
the  epithelium  still  persists,  and  of  interglandular  tissue.  The 
glands  also  penetrate  for  a  short  distance  into  the  muscular  coat, 
The  superficial  parts  of  the  deeper  layer  in  turn  undergo  de- 
generation, and  are  carried  away  in  the  lochia,  with  the  result 
that  the  surface  of  the  uterus  again  becomes  smooth.  Then, 
according  to  Leopold,  j  the  remains  of  the  glands  commence  to 

*  Trans.  Royal  Soc.  Edin.,  vol.  xxxv.,  part  ii. 

f  Archiv  f.  Gyn.,  vol.  xxiv.,  p.  400  ;  vol.  xxvi.,  p.  120. 

\  Ibid.,  vol.  xii.,  p.  169. 


444  THE  PHYSIOLOGY  OF  THE  PUERPERIUM 

increase  in  length  and  their  epithelium  proliferates,  until  at  about 
the  end  of  the  third  week  the  latter  reaches  the  level  of  the  uterine 
wall.  Finally,  about  the  fifth  to  the  eighth  week,  the  epithelial 
lining  of  the  uterus  is  complete.  The  placental  site  is  at  first 
covered  by  the  remains  of  decidua  serotina,  and,  consequently,  is 
slightly  raised.  As  involution  continues,  the  site  diminishes  in 
size,  but  bulges  rather  more  towards  the  uterine  cavity — a  change 
which  is  probably  due  to  the  formation  of  thrombi  in  the  placental 
sinuses.  The  covering  layer  of  decidua  degenerates,  and  the 
mucous  membrane  is  restored,  as  in  the  case  of  the  other  portions 
of  the  uterine  wall. 

The  Bloodvessels, — The  arteries  of  the  uterus  gradually  diminish 
in  size,  probably  as  a  result  of  the  compression  they  undergo,  but 
a  permanent  thickening  of  their  walls  persists.  Some  of  the  smaller 
vessels  are  obliterated  by  a  progressive  proliferation  of  the  con- 
nective tissue  of  the  intima,  the  muscular  coat  disappearing  as  a 
result  of  hyaline  or  fatty  degeneration.  Many  of  the  capillary 
vessels  are  completely  removed  by  hyaline  degeneration.  The 
uterine  sinuses  are  filled  by  thrombi,  some  of  which  appear  at  the 
time  of  delivery,  and  others  several  days,  or  even  several  weeks 
after  delivery.  The  subsequent  changes  which  take  place  in  the 
sinuses  very  closely  resemble  what  occurs  in  a  corpus  luteum. 
The  endothelium  proliferates  and  is  thrown  into  folds,  which,  as 
they  increase  in  size,  occupy  more  and  more  of  the  cavity.  The 
thrombus  gradually  shrinks  and  becomes  decolourised,  and  finally, 
perhaps,  its  remains  become  organised  by  the  outgrowth  into  them 
of  connective-tissue  cells  and  capillary  vessels.  At  the  end  of 
six  weeks  there  is  little  trace  of  the  former  sinus,  save  the  con- 
voluted appearance  of  the  lining  membrane  and  small  crystals  of 
haematoidin.* 

The  Lochia. — The  lochia  (Adxios,  of,  or  belonging  to,  child- 
birth), the  lochial  discharge,  or  the  cleansings  are  the  terms  applied 
to  the  discharge  which  comes  from  the  uterus  during  involution. 
The  old  and  classical  description  of  the  lochia  must  be  consider- 
ably modified  as  a  result  of  the  alterations  which  have  been  brought 
about  in  their  character  by  the  practice  of  aseptic  midwifery.  In 
the  past  it  has  always  been  customary  to  describe  three  forms 
of  lochia — the  lochia  rubra  or  omenta,  which  lasted  for  the  first  three 
days  ;  the  lochia  serosa,  which  lasted  until  the  sixth  or  seventh 
day ;  and  the  lochia  alba  or  lactea,  which  persisted  up  to  the  end 
of  the  second  or  third  week.  The  lochia  alba  or  lactea  may  in 
reality,  as  Giles  points  out,  be  considered  as  identical  with  the 
'  laudable  pus  '  of  pre-antiseptic  days,  and  consequently  as  non- 
existent in  the  course  of  an  aseptic  puerperium.  There  is  no 
advantage  in  adhering  to  this  old  description,  and  we  may  con- 
sider the  lochia  as  a  wound  discharge  consisting  of  blood  and 
serum,  to  which  is  added  fragments  of  decidua  and  membranes — 

*  Vide  also  a  paper  by  Sir  J.  Williams,  '  Changes  in  the  Uterus  resulting 
from  Gestation,'  Trans.  Obstet.  Society,  vol.  xx. 


Plate   VI. — Mesial    Sagittal    Section    of   . 
Thirty-six  Hours  after  Delivery. 


Woman    who    died 
(Webster.) 

[  To  face  p.  444. 


THE  LOCHIA 


445 


the  products  of  the  degeneration  of  decidual  tissue,  and  mucus 
from  the  cervical  glands.  At  first,  the  discharge  consists  of 
almost  pure  blood,  owing  to  the  large  extent  of  wound  surface, 
and  to  the  incomplete  obliteration  of  the  bloodvessels.  Later, 
the  blood  gradually  lessens  and  the  discharge  becomes  sero- 
sanguineous,  and,  finally,  the  blood  disappears,  and  the  discharge 
consists  of  a  purely  serous  transudation.  Consequently,  we  may 
expect  in  a  normal  puerperium  to  find  the  pads  which  are  placed 
over  the  vulva  at  first  soaked  by  almost  pure  blood,  then  stained 
with  bloody  serum,  and,  finally,  by  serum  alone.  Whether 
bacteria  are  necessarily  present  or  not  in  the  lochia  is  a  question 
which  has  given  rise  to  considerable  discussion,  and  which  we 
have  already  in  part  answered.  It  may,  we  think,  be  stated  that, 
if  the  patient  was  previously  healthy  and  the  labour  normal,  the 
vagina  will  be  sterile  after  delivery.  That,  if  the  parts  are  kept 
thoroughly  cleansed  and  protected  by  a  sterile  covering  during 
the  puerperium,  the  lochia  will  remain  aseptic.  That,  if  the 
vulva  is  not  protected  by  a  sterile  covering,  but  all  source  of 
infection  is  avoided,  the  lochia  will  contain  non-pyogenic  bacteria 
and  saprophytes,  which  have  entrance  by  direct  upward  ex- 
tension. Finally,  that,  if  pyogenic  bacteria  are  allowed  to  gain 
entrance  either  by  indirect  extension  from  without  or  by  direct 
introduction  on  the  fingers  or  instruments,  they  will  be  found 
in  the  lochia,  and  the  characters  of  the  latter  will  be  altered  in 
correspondence  with  the  nature  of  the  infecting  bacterium. 

The  quantity  of  lochia,  which  was  formerly  considered  to  be 
physiological,  is  considerably  in  excess  of  the  actual  quantity 
in  an  aseptic  case.  The  statistics  of  Gassner,*  which  have 
usually  been  accepted  in  the  past,  are  as  follows  : — 


Variety. 

Duration. 

Amount. 

Lochia  rubra 
Lochia  serosa 
Lochia  alba  - 

i  st  to  3rd  day. 
4th  to  5th  day. 
6th  to  8th  day. 

35  oz.     4'4  drms. 
9    ..     14 
7    ■■       36     ,, 

Total      - 

ist  to  8th  day. 

52  oz.     6  drms. 

Gassner  further  stated  that,  if  the  patient  nursed,  the  average 
loss  was  less,  and  averaged  38  ounces  4  drams  ;  while  if  she  did 
not  nurse  the  loss  was  greater,  and  amounted  to  66  ounces 
5  drams.  These  figures  are  manifestly  too  high,  and,  curious  as 
it  seems,  were  based  on  the  examination  of  only  two  cases,  so 
that  it  is  quite  time  that  they  are  no  longer  quoted  as  correct  in 
text-books. 

Giles  f  has  made  a  series  of  investigations  in  sixty  patients  in 
whom  the  puerperium  was  normal,  and  in  whom  he  measured 
the  amount  of  lochia  with  due  precaution  to  avoid  errors.     His 

*  Monatssch.  f.  Geburts.,  vol.  xix. ,  p.  51. 
t  '  Encycl.  Medica.,'  vol.  x.,  p.  138. 


446 


THE  PHYSIOLOGY  OF  THE  PUERPERIUM 


results  differ  considerably  from  those  of  Gassner,  and  are  as 
follows:— The  smallest  amount  of  lochia  in  any  case  was 
two  ounces,  the  greatest  amount  twenty-four  ounces.  In  thirty 
cases,  or  50  per  cent.,  the  quantity  was  ten  ounces  or  less.  In 
nine  cases,  or  32  per  cent,  the  quantity  was  ten  to  fifteen  ounces. 
In  eight  cases,  or  13  per  cent,  the  quantity  was  fifteen  to  twenty 
ounces.  In  three  cases,  or  5  per  cent.,  the  quantity  was  over 
twenty  ounces.  The  average  quantity  of  all  the  cases  was 
10-89  ounces,  and  if  the  three  cases  in  which  the  amount  was 
over  twenty  ounces  are  excluded,  the  average  of  95  per  cent,  of 
the  cases  is  about  io|  ounces.  The  duration  of  the  discharge 
was  found  to  be  as  follows  : — 


Number  of  Cases. 

Duration  in  Days. 

Number  of  Cases. 

Duration  in  Days. 

4 
4 

5 
6 

11 
6 

9 
10 

10 
11 

7 
8 

7 
6 

11 
12 

1 

14 

These  figures  show  an  average  duration  of  8f  days.  Further, 
Giles  did  not  find  that  the  quantity  of  lochia  was  considerably 
increased  in  the  case  of  women  who  did  not  nurse  their  infant. 
In  fifty-three  women  who  nursed,  the  average  quantity  was  11 -2 
ounces  ;  in  seven  women  who  did  not  do  so,  the  average  was 
10-3  ounces.  The  age  and  parity  of  the  patient  did  not  appear  to 
affect  the  quantity.  On  the  other  hand,  the  latter  varied  directly 
with  the  weight  of  the  infant,  and  especially  with  that  of  the 
placenta,  with  the  amount  of  blood  lost  at  the  time  of  labour, 
and  with  the  habitual  amount  of  the  menstrual  flow.  It  was  also 
greater  in  the  case  of  dark  than  fair  patients. 

The  Weight  and  Size  of  the  Uterus.  —The  effect  of  involution  on 
the  uterus  is,  as  has  been  stated,  to  bring  about  a  marked  reduc- 
tion in  its  weight  and  size.  The  weight  of  the  uterus  after 
delivery  varies  within  wide  limits  according  to  the  individual 
tendencies,  and  this,  in  all  probability,  accounts  for  the  rather 
different  figures  which  are  given  by  observers,  who  state  its 
weight  to  be  from  1  pound  10-5  ounces  (Borner*)  to  3^  pounds 
(Varnier  t).  At  the  end  of  two  days  the  weight  has  fallen  to  an 
average  of  one  and  a  half  pounds,  at  the  end  of  a  week  to  a 
pound,  at  the  end  of  two  weeks  to  three-quarters  of  a  pound, 
while  by  the  end  of  the  sixth  week  the  normal  weight  of  9  or  10 
drachms  is  reached  (Heschl). 

The  various  alterations  in  the  vertical  measurements  of  the 
uterus  as  collected  by  Giles}  are  as  follows  : — 

*  '  Ueber  den  puerperalen  Uterus.'     Graz,  1875. 
f  '  La  Pratique  des  Accouchements. '     Paris,  1900. 

+  Op.  cit. 


Plate  VII.— Mesial  Sagittal  Section  of  a  Woman  who  died  Sixty-eight 
Hours  after  Delivery.     (Varnier.) 

[To  face  p.  446. 


CHANGES  IN  THE  APPENDAGES  AND  LIGAMENTS        447 


Day. 

Cervix. 

Body. 

Whole  Uterus. 

Cavity. 

ISt 

8    inches 

7    inches 

2nd 

2\  inches 

4-!  inches 

7 

6}      „ 

3rd 

2 

4f      •- 

6f      ,, 

5t      ,, 

4th 

2 

si    .. 

7*     - 

6-i      ,, 

6th 

if      ■• 

3*      .. 

5i      ,. 

4f      -. 

i5th 

ii      ., 

2|        ,, 

3i  .. 

3t      •- 

The  height  of  the  uterus  above  the  symphysis  is  of  more  practical 
importance  than  the  measurements  we  have  just  given,  inasmuch 
as  clinically  it  is  the  means  by  which  we  judge  of  the  rate  of 
involution.  The  average  height  in  inches,  as  determined  by 
Stevens  and  Griffith*  during  the  twelve  succeeding  deliveries,  is 
as  follows  : — 


Height  above 

Day. 

Height  above 

Day. 

Symphysis. 

Symphysis. 

ISt 

5^  inches 

7th 

3^  inches 

2nd 

5 

8th 

3*       ., 

3rd 

4l 

gth 

2f 

4th 

4*       .. 

10th 

2^- 

5th 

4 

nth 

2\          ,, 

6th 

3*       ,. 

1 2th 

2$ 

In  measuring  the  height  of  the  uterus  we  must  first  ascertain 
that  the  bladder  is  empty,  and,  if  possible,  the  rectum,  and  that 
the  uterus  is  lying  in  a  mesial  plane,  and  is  not  unduly  deflected 
to  one  or  other  side.  A  full  bladder  or  a  distended  rectum  will 
push  the  uterus  upwards,  while,  if  the  uterus  is  deflected  to  one 
or  other  side  or  markedly  ante-  or  retro-verted,  the  fundus  will  lie 
at  a  lower  level  than  would  be  the  case  if  these  deviations  were 
corrected.  As  it  is  impossible  to  remember  a  list  of  figures  such 
as  the  above  for  clinical  purposes,  it  is  well  to  know  that  about 
the  fourth  day  the  fundus  should  be  at  or  just  below  the  level  of 
the  umbilicus,  while  by  the  tenth  day  it  should  lie  behind  the 
symphysis,  the  posterior  surface  of  the  body  occupying  the  plane 
of  the  brim.  On  the  fifteenth  day  it  is  an  entirely  pelvic  organ 
(Webster). 

The  Appendages  and  Ligaments. — As  we  have  already  seen,  the 
outer  extremities  of  the  tubes  do  not  alter  their  position  to  any 
great  extent  during  pregnancy,  and,  consequently,  as  the  uterus 
enlarges  the  tubes  come  to  lie  vertically  in  the  abdomen.  This 
position  is  maintained  during  the  first  few  days  of  the  puerperium, 
and  gradually  as  the  uterus  returns  to  its  normal  size  the  tubes 
regain  their  normal  more  or  less  horizontal  position.  The  tubes  and 
ligaments  undergo  a  process  of  involution  identical  with  that  of 


*  '  Variations  in  the  Height  of  the  Fundus  Uteri  above  the  Symphysis,'  etc. 
Obst.  Trans.  London,  vol.  xxxvii.,  p.  246. 


448  THE  PHYSIOLOGY  OF  THE  PUERPERIUM 

the  uterus,  and,  when  this  process  is  complete,  they  occupy  very 
much  the  same  relations  to  the  uterus  as  before  impregnation. 

The  Vagina.  —  The  vaginal  canal  after  delivery  is  soft  and 
dilated,  and  in  the  case  of  primiparae  is  frequently  lacerated  in 
its  lower  part.  At  the  end  of  two  to  four  weeks,  according  to 
the  rate  at  which  involution  takes  place,  it  has  regained  its 
normal  size,  but  some  increase  in  size  probably  always  persists, 
especially  at  the  vulvo- vaginal  junction. 

The  Perinasum  and  Pelvic  Floor. — The  involution  of  the  peri- 
naeum  is  complete  in  about  fourteen  days.  Lacerations  and 
abrasions,  if  correctly  treated,  will  also  heal  within  the  same 
period.  The  projection  of  the  pelvic  floor,  which  we  know  to 
occur  during  pregnancy,  is  even  more  marked  about  the  fourth 
day  of  the  puerperium  than  it  was  previously.  According  to 
Webster,  it  is  as  follows  : — First  day,  2  inches ;  second  day, 
i|-  inches  ;  third  day,  if-  inches  ;  fourth  day,  2^  inches  ;  sixth 
day,  1 J  inches  ;  fifteenth  day,  1  inch. 

Changes  in  the  Breasts. 

As  lactation  is  establishing  itself,  the  breasts  become  swollen 
and  tender,  the  superficial  veins  ■  engorged,  and  frequently  the 
axillary  glands  enlarged.  Histologically,  the  following  changes 
have  been  noticed.  The  alveoli  of  the  glands  are  found  to  be 
lined  with  cells,  which  are  cubical  or  columnar  according  as  they 
are  distended  or  collapsed,  and  within  the  distended  alveoli  is 
found,  in  prepared  specimens,  a  finely  granular  material  formed 
by  the  coagulation  of  caseinogen.  In  some  of  the  cells,  more  than 
one  nucleus  is  present,  but  karyokinetic  figures  and  cell  division 
do  not  appear  to  occur  more  frequently  than  in  the  non-lactating 
condition.  Within  many  of  the  cells,  oil  globules  can  be  distin- 
guished, and  in  some  alveoli  the  central  end  of  the  cells  presents  a 
ragged  appearance,  suggesting  that  this  part  of  the  cells  them- 
selves breaks  down  to  form  the  solids  of  the  milk.  It  is  probable, 
however,  that  this  does  not  actually  occur,  but  that  the  milk  is  a 
true  secretion  formed  by,  and  passed  out  from,  the  cells  without 
any  breaking  down  of  cellular  substance  taking  place.  In  the 
early  days  of  lactation,  cells  distended  with  fat  globules,  and 
known  as  colostrum  corpuscles,  are  found  in  the  milk.  These 
were  formerly  regarded  as  desquamated  alveolar  cells,  but  it  is 
now  almost  universally  believed  that  they  are  really  migrated 
leucocytes. 

Colostrum  is  the  term  applied  to  the  fluid  which  comes  away  in 
the  first  forty-eight  hours  after  delivery,  or,  perhaps  it  would  be 
more  correct  to  say,  from  the  time  of  delivery  until  the  secretion 
of  the  true  milk  is  established.  It  is  of  a  deep  yellow  colour,  due 
to  the  presence  of  colostrum  corpuscles,  is  strongly  alkaline  in 
reaction,  and  coagulates  into  a  solid  mass  if  heated,  and  some- 
times even   coagulates  spontaneously.     The  fat  globules  are  of 


Plate  VIII.— Mesial  Sagittal  Section  of  a  Woman  who  died  Twenty-six 
Days  after  Delivery.     (Varnier.) 

[To  face  p.  448. 


CHANGES  IN  THE  ORGANISM  IN  GENERAL 


449 


very  unequal  size,  and  the  number  of  colostrum  corpuscles 
present  is  considerable.  As  will  be  seen  by  comparing  its 
analysis  with  that  of  human  milk,  it  contains  a  considerably 
larger  quantity  of  proteid  matter,  and  only  slightly  more  than 
half  the  proportion  of  fat  and  sugar.  The  laxative  effect  which 
it  produces  on  the  infant  is  said  by  Winckel*  to  be  due  to  the 
presence  of  calcium  phosphate,  magnesia,  and  sodium  and 
potassium  chloride.  The  colostrum  corpuscles  disappear  in 
from  three  to  five  days. 

The  secretion  of  the  true  milk  commences,  as  a  rule,  on  the 
third  or  fourth  day  after  delivery,  and  in  a  few  cases  a  little 
earlier  or  later,  as  is  shown  by  the  following  table  (M'Cann  and 
Turner)  : — f 

Secretion  commences  on  the  ist  day  in  i  per  cent,  of  cases. 


2nd 

,,      5 

3rd 

4th 

.,         5th 

6th 

,,    46         „ 
,-    39 
,,      6 

1          ,, 

after  the  6th 

2 

The  average  daily  quantity  of  milk  secreted  is  difficult  to 
ascertain  with  certainty,  and  differs  considerably  in  different 
women,  and  in  the  same  woman  according  to  the  demand  made 
upon  her  by  the  infant.  The  following  table  has  been  compiled 
by  HoltJ  from  observations  made  in  five  cases,  in  all  of  which 
the  infants  were  healthy,  were  exclusively  breast-fed,  and  gained 
steadily  in  weight :  — 


Periud. 

A 

/eraye  daily  quantity. 

End  of  ist  week 

- 

-     10  to  i6-ounces 

During  2nd  week    - 

- 

-     13   ,.   18       .. 

3rd     -. 

- 

-     14  ..  24       ,, 

4th     ,, 

- 

-     16  „  26 

From  5th  to  13th  week 

- 

-     20   ,,  34 

4th   „  6th  month 

- 

-     24   „  38       „ 

6th   ,,  gth 

- 

-     30   ,,  4° 

The  composition  of  human  milk  and  of  colostrum  will  be  dis- 
cussed in  another  place. 

Changes  in  the  Organism  in  General. 

The  various  general  changes  which  occur  during  the  puerperium 
will  be  considered  under  their  proper  heads. 

The  Circulatory  System. — The  hypertrophy  of  the  heart,  which 
usually  occurs  during  pregnancy,  gradually  disappears,  and  the 
apex-beat  returns  to  its  normal  position.  In  a  considerable  pro- 
portion of  cases  a  modification  of  the  first  cardiac  sound,  which  is 
replaced  by  a  soft  blowing  murmur,  can  be  noticed.     This  occur- 

*  Op.  cit.,  p.  201. 

t  '  Occurrence  of  Sugar  in  the  Urine  during  the  Puerperium,'  Obst.  Trans. 
Loud.,  vol.  xxxiv.,  pp.  473-487. 

X  'Diseases  of  Infancy  and  Childhood,'  p.  128.  Cases  recorded  by 
Hsehner  (3),  Laure,  and  Ahlfeld. 

29 


4 so  THE  PHYSIOLOGY  OF  THE  PUERPERIUM 

rence  was  first  detected  by  Money,  and  was  found  by  Dakin  in 
57  out  of  ioo  cases  specially  examined  at  the  General  Lying-in 
Hospital.  It  is  probably  associated  with  the  involution  of  the 
cardiac  muscle. 

The  pulse  of  the  parturient  woman  is,  as  a  rule,  slower  than 
the  normal,  but  not  perhaps  to  the  extent  that  was  at  one  time 
considered  to  be  the  case.  Considerable  differences  of  opinion 
have  been  expressed  as  to  the  alteration  of  rate  which  occurs. 
Olshausen*  found  a  pulse-rate  of  below  60  in  63  per  cent,  of 
cases.  Spiegelberg  t  stated  that  '  the  pulse-rate,  which  has  in- 
creased during  labour,  diminishes  immediately  after  it,  then  rises 
again,  and  on  the  second,  third,  or  fourth  day  becomes  markedly 
slowed.  The  rate  then  varies  between  44  and  70 ;  indeed,  a 
frequency  of  less  than  40,  even  of  30,  has  been  noticed.  The 
usual  figures  are  44,  48,  and  56.'  This  statement  was,  however, 
challenged  by  Probyn- Williams  and  Cutler,  J  who  found  that 
in  100  cases  examined  at  the  General  Lying-in  Hospital  the 
average  rate  was  never  lower  than  73,  and  oftener  nearer  80 
than  70.  The  pulse  of  a  puerperal  woman  is  readily  influenced 
by  conditions  which  at  other  times  would  produce  little  or  no 
effect,  and,  consequently,  alterations  in  its  rate  are  of  frequent 
occurrence,  and  the  difficulty  of  obtaining  the  correct  average 
rate  is  considerable.  It  is  more  than  probable  that  a  slight 
degree  of  slowing  generally  occurs,  and  that  whereas  the  average 
pulse-rate  varies  in  pregnancy  between  70  and  80,  the  average 
pulse-rate  in  the  puerperium  is  between  60  and  70.  The  causes 
which  produce  this  slowing  have  been  variously  stated  to  be 
altered  innervation  of  the  cardiac  muscle,  increased  arterial 
tension,  the  horizontal  position  of  the  patient,  the  presence  of 
fat  in  the  circulation  due  to  absorption  from  the  uterus,  and 
the  impoverishment  of  the  blood  from  haemorrhages  during 
labour.  A  probable  cause  would  seem  to  be  the  re-action  of  the 
system  generally  from  the  increased  strain  imposed  upon  it  by 
pregnancy  and  labour  ;  but,  inasmuch  as  slowing  has  been  noticed 
after  a  four  months'  abortion,  some  other  cause  or  causes  must 
also  be  at  work. 

The  blood  is  said  to  contain  a  larger  proportion  of  fibrin  and 
white  blood  corpuscles  than  during  pregnancy.  This  increase 
reaches  a  maximum  twelve  hours  after  labour,  and  has  been 
termed  a  physiological  leucocytosis. 

The  Temperature.  —  It  cannot  be  too  plainly  and  definitely 
stated  that,  though  the  puerperal  woman  is  subject  to  slight 
variations  of  temperature,  the   average  temperature  differs  but 

*  '  Ueber  die  Pulsverlangs.  im  Wochenbette,'  etc.,  Cent.  f.  Gyn.,  1881, 
Nr.  iii.  3,  pp.  49-53. 

f  'Text-book  of  Midwifery,'  New  Sydenham  Society's  edition,  vol.  i. , 
p.  289. 

%  'Some  Observations  on  the  Temperature,'  etc.,  Trans.  Obstet.  Soc.  Lond., 
vol.  xxxvii.,  pp.  26,  29. 


CHANGES  IN  THE  ORGANISM  IN  GENERAL  451 

little,  if  at  all,  from  the  normal.  Temporary  variations  of 
temperature,  reaching,  perhaps,  as  high  as  ioo*5°  F.,  may  occur, 
for  which  it  is  difficult  to  find  a  cause  ;  but  for  temperatures  above 
that  a  cause  can  be  found  in  almost  every  case.  Up  to  com- 
paratively recent  times,  it  was  a  common  belief  that  a  physio- 
logical elevation  of  temperature,  reaching  1010  F.,  or  higher, 
occurred  on  the  third  or  fourth  day  in  association  with  the 
establishment  of  lactation.  To  this  condition  the  term  '  milk- 
fever  '  was  applied,  and  in  consequence  of  the  general  belief  in 
its  physiological  nature,  local  septic  conditions  of  the  genital 
tract  were  overlooked.  A  rise  of  temperature  of  from  0-5°  F.  to 
o*8°  F.  during  the  first  twelve  hours  after  delivery  is  perhaps  the 
rule,  and  this  rise  is  most  marked  when  the  hours  of  4  p.m.  to 
8  p.m.  fall  within  this  period  — -  that  is  to  say,  when  the  post- 
parturient  rise  corresponds  with  the  ordinary  evening  elevation  of 
temperature. 

The  Urinary  System. — The  secretion  of  urine  during  the  first 
days  of  the  puerperium  is  increased,  and  averages  about  2,020 
grammes  in  the  twenty-four  hours.  This  increase  affects  in  the 
main  the  water,  as  there  is  little  or  no  increase  in  the  amount  of 
solids  excreted.  The  amount  of  urea,  sulphates,  and  phosphates 
is  actually  diminished  during  the  first  two  or  three  days,  increases 
slightly  about  the  fourth  day,  and  then  again  progressively 
diminishes.  The  chlorides  are  considerably  increased  (Winckel). 
The  specific  gravity,  which  at  first  varies  between  1,010  and 
1,018,  reaches  a  maximum  of  about  1,022  on  the  fourth  day. 
The  presence  of  sugar  in  the  urine,  which  at  one  time  was 
considered  doubtful,  is  now  generally  admitted.  Hofmeier  and 
Kaltenbach:;:  were  the  first  to  demonstrate  that  it  occurred  as 
lactose,  and  so  to  prove  the  intimate  connection  between  its 
presence  and  lactation. 

This  connection  has  been  still  further  cleared  up  by  MacCann 
and  Turner.!  Their  investigation  of  100  cases  snowed  that 
lactosuria  occurred  in  all  after  lactation  had  started,  and  that 
the  average  quantity  of  sugar  was  about  i-J  grains  to  the  ounce. 
Excessive  production  of  milk  or  diminished  outflow  resulted  in 
an  increase  in  the  quantity,  while  as  soon  as  production  and 
withdrawal  from  the  breast  became  equal  the  amount  of  sugar  in 
the  urine  became  constant.  Although  the  quantity  of  milk  affects 
the  amount  of  lactose,  the  quality  does  not,  and,  consequently, 
the  proportion  of  lactose  is  not,  as  was  at  one  time  stated,  a  guide 
to  the  suitability  of  a  wet-nurse. 

The  presence  of  peptone  in  the  urine  during  the  puerperium 
has  also  been  determined  (Fischer}),  and  would  appear  to  be 
fairly  constant.  It  appears  about  the  second  or  third  day  after 
delivery,  the  proportion  increases  up  to  the  fourth  day,  and  then 
diminishes  gradually  until  it  disappears  about  the  tenth  or  twelfth 
day.     Its  presence  is  probably  connected  with  the  changes  which 

*  Zeits.  f.  Geb.  u.  Gyn.,  vol.  i v.,  p.  161.  \  Op.  cit.  J  Ibid. 

29 — 2 


452 


THE  PHYSIOLOGY  OF  THE  PUERPERIUM 


occur  in  uterine  muscle  fibres  during  involution.  Small  quantities 
of  acetone  have  also  been  found  in  the  normal  puerperal  urine — 
a  fact  of  some  importance,  in  view  of  the  statement  that  such  an 
occurrence  prior  to  delivery  indicated  the  death  of  the  foetus 
(Vicarelli,*  Knappf). 

The  Digestive  System. — The  appetite  of  the  patient  for  the  first 
two  or  three  days  is  usually  somewhat  diminished,  but  from  that 
time  on,  as  the  demands  made  by  lactation  produce  their  effect,  it 
increases.  Thirst  is  usually  keen  from  the  first,  in  consequence 
of  the  loss  of  blood  during  labour,  and  later  as  a  result  of  lactation. 
The  bowels  are  almost  always  confined,  and  it  is  but  rarely  that 
a  movement  will  occur  during  the  lying-in  unless  brought  about 
by  a  purgative  or  enema.  This  is  due  in  part  to  the  relaxed 
abdominal  walls  and  the  lowered  intra-abdominal  tension,  in  part 
to  the  recumbent  position  and  lack  of  exercise.  Digestive 
troubles,  nausea,  etc.,  which  may  have  caused  considerable 
annoyance  during  the  end  of  pregnancy,  usually  disappear  with 
the  expulsion  of  the  foetus. 

In  consequence  of  the  increased  action  of  the  kidneys  and 
skin,  of  the  involution  of  the  uterus,  and  of  the  diminished 
ingestion  of  food,  there  is  a  distinct  loss  of  weight  in  a  puerperal 
woman  during  the  first  eight  days,  and  this  has  been  found  to 
amount  to  an  average  of  10  pounds  (4,571  grammes,  Gassner.{), 
This  loss  of  weight  was  considered  by  Winckel  to  be  abnormal, 
and  partly  due  to  insufficient  diet ;  but  a  series  of  experiments 
made  by  Baumm§  at  Munich  showed  that  a  loss  of  weight  of 
from  1,700  to  6,500  grammes  (3  pounds  11  ounces  to  14  pounds 
5  ounces)  normally  occurred,  and  that  the  average  loss  was 
7  pounds  8  ounces.  Further,  multipara?,  and  those  who  nursed 
frequently,  lost  more  than  primiparae  and  non-nursing  women  ; 
the  greater  the  weight  of  the  individual  the  greater  was  the  loss, 
and  after  twins  it  was  more  marked  than  after  single  pregnancies. 

It  is  interesting  to  compare  with  these  figures  the  loss  of 
weight  during  labour.  The  following  figures  are  also  the  result 
of  Baumm's  researches,  and  are  based  on  sixty  cases : — 


The  foetus 
Placenta  - 
Liquor  amnii 
Blood 

Excrementa 

Evaporation  from    lungs 
and  skin 


3,265  grms.  (  7  lb. 

628      ,,       (  1  lb. 
1,300      ,,       (  2  lb. 

308      ,,      ( 

366      „      ( 


375 


3  oz.  approx. ) 

6  oz.  2  drms.  approx.) 
13  oz.  13  drms.  approx.) 
10  oz.  13  drms.  approx.) 

12  oz.  14  drms.  approx.) 

13  oz.    3  drms.  approx.) 


Total  loss  during  labour     6,242 
Total   loss   during   puer- 

perium  -  -     3,399 


Total  loss  from  com- 
mencement of  labour 
to  end  of  puerperium     9,641 


(13  lb.  12  oz.  approx.) 
(  7  lb.    8  oz.  approx.) 

(21  lb.    4  oz.  approx.) 


*  Prag.  Med.  Wochensch.,  1893. 

+  Monatssch.  f.  Geburts.,  vol.  xix.,  p.  47. 


f  Cent.  f.  Gyn,,  1897,  p.  417. 
§  I.,  D.,  Miinchen,  p.  18. 


CHANGES  IN  THE  ORGANISM  IN  GENERAL  453 

The  Respiratory  System  and  Skin — The  rate  of  respiration  is 
slightly,  if  at  all,  affected  during  a  normal  puerperium.  Imme- 
diately after  delivery  it  averages  from  14  to  20,  and  during  the 
puerperium,  according  to  Probyn  -  Williams  and  Cutler, *  the 
average  rate  is  from  20  to  22. 

The  skin  acts  freely  during  the  puerperium,  and  is  a  valuable 
adjunct  to  the  eliminatory  functions  of  the  kidney.  The  pig- 
mentation of  pregnancy  passes  off  within  a  few  weeks,  and  the 
red  striae  gravidarum  gradually  change  into  lineae  albae.  In  a 
certain  proportion  of  women  (27  out  of  377,  Champneys)  lumps 
appear  in  the  skin  of  the  axillae  towards  the  end  of  pregnancy, 
and  are  especially  noticeable  during  the  puerperium.  These 
lumps  vary  in  size  from  "  the  smallest  possible  "  to  that  of  an  egg 
or  a  little  larger.  If  they  are  squeezed  during  the  puerperium, 
granular  debris  like  the  secretion  of  sebaceous  follicles  is  expelled 
through  their  ducts,  and  is  followed  by  a  substance  resembling 
colostrum,  and,  finally,  by  what  appears  to  be  milk.  The 
secretion  does  not  flow  naturally  from  them,  as  happens  in  the 
breast.  It  was  at  first  considered  that  these  lumps  were  modified 
sebaceous  glands,  but  they  have  more  recently  been  found  to  be 
modified  sweat-glands. f  They  are  situated  in  the  skin,  and  in  half 
the  cases  occur  bi-laterally.  Their  course  of  enlargement  follows 
that  of  the  breast,  and  sometimes  they  may  again  become  swollen 
and  slightly  painful  during  subsequent  menstruations. 

The  Abdominal  Walls. — The  abdominal  walls  have  of  necessity 
become  considerably  stretched  during  pregnancy,  and  conse- 
quently after  delivery  are  flaccid  and  wrinkled.  Under  ordinary 
circumstances  this  condition  passes  off  to  a  great  extent  during 
the  first  two  months  after  delivery.  A  certain  amount  of  laxity 
and  wrinkling,  however,  always  persists  after  the  first  pregnancy. 
If  there  has  been  excessive  overdistension,  or  if  the  woman  has 
had  many  previous  pregnancies,  the  recti  muscles  may  become 
separated  in  consequence  of  the  stretching  of  the  common  tendon 
of  the  internal  oblique  and  the  transversalis  muscles.  As  a  result 
of  this,  the  intestines  bulge  between  the  separated  muscles  when- 
ever the  woman  strains,  and,  if  the  lateral  muscles  of  the  abdominal 
wall  are  also  overstretched,  a  pendulous  abdomen  results.  The 
striae  gravidarum,  which  occurred  during  pregnancy,  gradually 
lose  their  reddish  colour  and  become  white,  scar-like  lines — 
lineae  albae. 

The  Pelvic  Joints. — The  relaxation  of  the  pelvic  joints  which 
occurs  towards  the  end  of  pregnancy,  and  which  permits  of  the 
occurrence  of  a  slight  range  of  movement  in  the  joints,  gradually 
passes  off  and  the  latter  regain  their  former  rigid  condition. 

*  Op.  at. 

t  '  On  the  Development  of  Mammary  Functions  by  the  Skin  of  Lying-in 
Women,'  by  F.  H.  Champneys,  Med.  and  Chir.  Trans.,  vol.  lxix.,  p.  419; 
Trans.  Obstet.  Soc.  Loud.,  vol.  xxxii.,  p.  117;  and  Champneys  and  Bowlby, 
Med.  and  Chir.  Trans.,  vol.  lxxviii. 


454  THE  PHYSIOLOGY  OF  THE  PUERPERIUM 

Symptoms. — The  symptoms  or  subjective  phenomena  of  a 
normal  puerperium  are  slight.  As  soon  as  labour  is  complete 
the  patient  experiences  a  sense  of  relief  which  is  in  marked  con- 
trast to  her  former  pain-harassed  condition.  During  the  days  of 
the  lying-in,  the  patient  is  in  a  state  of  general  comfort  and  well- 
being,  to  which,  for  the  last  month  of  pregnancy,  she  had  been 
a  stranger.  The  first  desire  is,  perhaps,  for  a  drink,  as  the  loss 
of  blood  during  the  third  stage  increases  the  thirst  which  suffering 
causes.  Then,  an  hour  or  so  after  delivery,  a  desire  for  food 
asserts  itself,  and  during  the  entire  puerperium,  as  has  been  said, 
the  appetite  is  good.  As  a  rule,  the  patient  experiences  a  desire 
to  micturate  during  the  first  twelve  hours  after  delivery,  or,  at 
any  rate,  will  be  able  to  empty  the  bladder  when  the  necessity 
for  so  doing  is  pointed  out  to  her.  In  a  not-inconsiderable  pro- 
portion of  cases,  on  the  other  hand — especially  amongst  primi- 
parae— not  only  is  there  no  desire  to  pass  water,  but  even  the  act 
of  so  doing  is  for  some  hours  impossible.  The  causes  of  such 
a  condition  are  readily  understood.  The  bruising  which  the 
urethra  undergoes  during  delivery,  especially  amongst  primiparae, 
causes  a  tenderness  which  renders  the  patient  reluctant  to  try  to 
empty  the  bladder,  and  also,  in  some  cases,  produces  a  temporary 
paralysis  of  the  sphincter.  Further,  the  diminished  intra-abdominal 
tension  and  the  relaxed  condition  of  the  abdominal  muscles  render 
the  emptying  of  the  bladder  difficult,  even  if  relaxation  of  the 
sphincter  is  obtained.  Observations  made  upon  224  women  who 
were  confined  at  term  in  the  Clinic  Baudelocque  (Recht*)  gave 
the  following  results  : — - 

51  women,  or  22  76  per  cent.,  passed  water  in  the  first  6  hours. 

79  ,,  35"26  ,,  ,,  between  the  7th  and  the  12th  hour. 

46  ,,  20-54  ..  ..  ..  I3th        .1        xSth.      ,, 

33  ..  i4'75  ■-  ..  ..  19th        ,,        24th      ,, 

15  ,.  6-69  ,,  ,,  ,,  25th        ,,        36th 

As  it  is  usually  taught  that  it  is  inadvisable  to  allow  a  patient 
to  remain  more  than  twelve  hours  without  having  emptied  the 
bladder,  the  above  table  shows  that  94  of  the  patients,  or 
41*98  per  cent.,  required  assistance,  and  this  figure  is  made  up 
of  59*21  per  cent,  of  the  primiparae  and  27*27  per  cent,  of  the 
multipara?  upon  whom  the  observations  were  made.  The  high 
proportion  amongst  primiparae  is  accounted  for  by  the  fact 
that  in  their  case  labour  is  more  prolonged  and  the  bruising  to 
which  the  parts  are  subjected  is  more  severe. 

The  bowels  seldom  act  of  their  own  accord  so  long  as  the 
woman  is  in  bed,  in  part  due  to  the  effect  of  the  recumbent 
position,  and  in  part  the  result  of  the  relaxed  condition  of  the 
abdominal  walls  and  the  lowered  intra-abdominal  pressure. 

Occasional  pains  due  to  contractions  of  the  uterus  are  of  not  in- 
frequent occurrence,  and  are  known  as  after-pains.  Contractions 
of  the  uterus  occur,  in  all  probability,  during  a  considerable  part  of 
*  These  de  Paris,  1894. 


THE  DIAGNOSIS  OF  RECENT  DELIVERY  455 

the  puerperium,  but  only  occasionally  are  they  so  well  marked  as 
to  give  rise  to  pain.  If  the  length  of  labour  is  normal,  and  if  the 
uterus  contracts  well  during  and  immediately  subsequent  to  the 
third  stage,  after-pains  rarely  occur.  If,  on  the  other  hand,  labour 
is  short,  and  if  incomplete  contraction  and  retraction  allows  the 
accumulation  of  clots  in  the  uterus,  after-pains  are  of  common 
occurrence.  Accordingly,  as  would  be  expected,  they  are  usually 
absent  in  primiparae  and  of  common  occurrence  in  multiparas. 
They  are  usually  most  marked  on  the  evening  of  the  first  day, 
and  in  some  cases  they  may  persist  for  several  days.  When  the 
infant  is  put  to  the  breast  they  become  momentarily  worse,  owing 
to  the  increased  contraction  of  the  uterus  caused  by  suckling. 

The  enlargement  of  the  breasts  and  the  establishment  of  lacta- 
tion are  usually  associated  with  slight  stinging  pains  in  the  breasts, 
and  of  continuous  and  severe  pain  if  overdistension  occurs.  If 
the  child  is  very  vigorous,  its  efforts  at  suckling  may  often  cause 
considerable  pain  and  sometimes  laceration  of  the  tender  skin 
about  the  base  of  the  nipples. 

When  the  patient  is  allowed  up  for  the  first  time  she  almost 
invariably  suffers  from  a  degree  of  muscular  weakness  the  exist- 
ence of  which  she  did  not  suspect  when  in  bed.  This,  however, 
soon  passes  off,  and  in  a  comparatively  short  time  afterwards  she 
regains  her  habitual  strength  and  energy.  If,  after  she  has 
returned  to  her  ordinary  mode  of  life,  she  still  suffers  from 
weakness  and  lassitude,  there  is  always  some  pathological  condi- 
tion present  whose  nature  should  be  determined  and  whose  cause, 
if  possible,  removed. 

Diagnosis. — It  occasionally  happens  that  in  legal  cases  it  may 
be  necessary  to  determine  whether  recent  delivery  has  occurred 
or  not.  In  these  cases,  the  statements  of  the  woman  concerned 
possess  only  a  negative  value,  and  the  diagnosis  must  be  made 
from  the  more  positive  information  obtained  from  the  physical 
examination  of  the  patient.  The  signs  upon  which  we  rely  for 
a  diagnosis  can,  as  in  the  case  of  pregnancy,  be  divided  into  three 
classes — doubtful,  probable,  and  certain. 

The  doubtful  signs  are  to  be  found  in  the  relaxed  and  wrinkled 
abdominal  wall,  the  presence  of  striae  or  lineae  albicantes,  of 
pigmentation,  and  of  varicose  veins. 

The  probable  signs  consist  in  lacerations  about  the  perinaeum 
cervix  and  vagina,  and  in  the  dilated  vagina,  the  enlargement  of 
the  uterus,  the  patulous  condition  of  the  cervix,  the  dilated  and 
relaxed  lower  uterine  segment,  the  dilated  uterine  cavity,  the 
roughened  area  corresponding  to  the  placental  site,  the  swollen 
and  secreting  breasts,  and  the  lochial  discharge. 

The  certain  signs  are  the  foregoing,  when  occurring  in  con- 
junction and  gradually  altering  within  a  short  period  in  the 
manner  previously  described.  Further,  the  presence  of  a  portion 
of  placenta  or  membrane  in  the  vagina,  or  attached  to  the 
placental  site,  is  per  se  a  certain  sign. 


CHAPTER  II 
THE  MANAGEMENT  OF  THE  PUERPERIUM 

The  Maintenance  of  the  Normal  Functions  of  the  Body — Digestion — The 
Bladder — The  Rectum.  The  Promotion  of  the  Functions  Peculiar  to  the 
Puerperium — Involution — The  Use  of  Vaginal  Douches — Lactation — 
General  Points  in  Treatment — Prognosis. 

The  management  of  the  puerperium  may  be  stated  in  a  few 
words  to  consist  in  attention  to  the  following  points  : — 

(i)  The  maintenance  of  the  ordinary  functions  of  the  body. 

(2)  The  promotion  of  the  functions  peculiar  to  the  puerperium 
—  i.e.,  involution  and  lactation. 

The  Maintenance  of  the  Normal  Functions  of  the  Body. 

The  functions  of  the  body,  to  which  attention  must  be  par- 
ticularly directed  during  the  puerperium,  are  the  digestive  functions 
and  the  functions  of  the  bladder  and  rectum. 

Digestion. — The  food  of  a  puerperal  woman  must  be  simple, 
sufficient,  and  appetising.  At  a  time  when  the  system  in  general 
is  recovering  from  the  strain  which  has  been  placed  upon  it  during 
the  previous  nine  months  and  is  accustoming  itself  to  the  perform- 
ance of  new  duties,  the  organs  of  digestion  must  not  be  over- 
taxed by  food  which  is  difficult  of  assimilation,  and,  accordingly, 
the  food  given  to  the  patient  must  be  simple.  When  the  woman 
is  up  and  able  to  take  a  due  amount  of  exercise,  a  correspondingly 
simple  but  more  varied  dietary  may  be  allowed.  At  all  periods 
of  the  puerperium,  the  amount  of  food  must  be  sufficient.  The 
older  notions  that  a  low  diet  was  required  at  this  time,  have  in 
the  words  of  a  recent  writer  been  consigned  to  the  same  limbo 
of  defunct  prescriptions  as  the  '  starve  a  fever  '  principle.  A 
puerperal  woman,  more  than  other  people,  requires  the  maximum 
amount  of  nourishment  which  she  can  digest  without  imposing 
too  great  a  tax  on  her  digestive  organs,  and  in  this  respect  the 
inclinations  of  the  patient  may  be  taken  as  a  guide.  For  the  first 
two  days,  light  nutritious  and  liquid  food  is  all  that  is  required, 
the  only  solid  food  for  which  the  patient,  as  a  rule,  cares  being 
toast  or  rusks,  or  a  light  milk  pudding.  On  the  third  day,  if 
the  bowels  have  acted,  food  of  a  more  solid  nature  may  be  given 

456 


MANAGEMENT  OF  THE  BLADDER  DURING  J'UERPERIUM     457 

in  small  quantities,  and  supplemented  as  required  by  liquids. 
From  this  onwards,  the  dietary  becomes  more  liberal,  but,  so 
long  as  the  patient  remains  in  bed,  her  meals  should  be  given  at 
short  intervals  and  small  amounts  of  food  only  be  taken  at  a 
time.  All  food  should  be  prepared  in  such  a  manner  as  to  be 
appetising,  as,  even  if  the  appetite  is  good,  the  squeamishness 
and  nervous  excitability  of  pregnancy  will  not  have  sufficiently 
passed  off  to  enable  the  patient  to  consume  the  necessary  quantity 
of  food  when  the  dietary  is  untempting.  For  this  reason,  there 
should  be  considerable  variety  in  the  food. 

It  is  unnecessary  to  enter  into  many  particulars  with  regard 
to  the  exact  dietary  adopted,  as  there  are  such  wide  limits  within 
which  it  may  vary  in  individual  cases.  The  general  principles 
which  govern  it  will  be  gathered  from  the  preceding  paragraph, 
and  from  the  following  : — During  the  first  two  days,  the  patient 
should  receive  some  nourishment  every  three  hours  during  the 
day.  Beef-tea,  milk,  chicken-tea,  gruel,  tea  and  toast,  an  egg 
well  beaten  up,  and  a  light  pudding  composed  of  egg  and  milk, 
may  in  turn  be  given  and  will  furnish  sufficient  variety.  If  the 
patient  proposes  to  nurse  the  infant,  abundance  of  milk  in  different 
forms  must  be  given.  If  she  is  not  going  to  nurse  the  infant,  the 
amount  of  milk  is  best  restricted.  On  the  third  to  the  fifth  day, 
the  woman  usually  experiences  a  desire  for  solid  food.  As  a 
Continental  writer  says,  '  the  English  puerpera  eats  her  beef- 
steak at  this  time  with  great  relish,'  and  if  for  '  beefsteak '  we  sub- 
stitute a  small  piece  of  fresh  fish,  of  chicken,  or  of  mutton  chop, 
she  not  only  relishes  the  change,  but  is  considerably  benefited  by 
it.  From  this  on,  the  interval  between  the  meals  may  be  increased, 
but  an  interval  of  four  hours  should  not  be  exceeded. 

The  use  of  alcoholic  beverages  as  stimulants  is  only  necessary 
when  the  patient  is  in  a  weak  condition  from  previous  ill-health 
or  haemorrhage.  As  a  food  or  tonic,  however,  and  particularly 
in  the  case  of  a  woman  who  is  nursing,  the  use  of  sound  claret, 
burgundy,  or  stout  may  be  permitted,  and  in  some  cases  will 
enable  a  patient  to  nurse  who  might  not  otherwise  have  been  able 
to  do  so. 

The  Bladder. — Attention  to  the  bladder  is  one  of  the  most 
important  duties  of  the  nurse  during  the  first  twenty-four  hours 
after  delivery.  In  no  case  should  a  parturient  woman  be  allowed 
to  pass  more  than  sixteen  hours  without  emptying  the  bladder, 
in  spite  of  what  has  been  written  by  Varnier  to  the  contrary 
effect.  According  to  the  statistics  which  we  quoted  in  the 
previous  chapter,  forty-two  per  cent,  of  women  will  not  pass  water 
within  the  first  twelve  hours  of  their  own  accord,  and,  conse- 
quently, in  all  these  cases  steps  must  be  taken  to  ensure  that 
the  bladder  is  emptied.  To  this  end,  after  twelve  hours  have 
elapsed,  warm  stupes  may  be  placed  over  the  pubes,  as  this 
often  produces  the  required  effect.  If  this  is  unsuccessful,  the 
patient    may   be    cautiously   turned    on    her   hands    and    knees, 


453  THE  PHYSIOLOGY  OF  THE  PUERPERIUM 

always  providing  that  there  is  no  laceration  of  the  perinaeum 
nor  cardiac  weakness.  If  this  still  is  unsuccessful,  and  if 
the  bladder  is  not  unduly  distended,  as  ascertained  by  abdo- 
minal palpation,  the  patient  may  wait  for  three  or  four  hours 
longer,  and  then,  if  the  application  of  stupes  and  alteration  of  the 
position  still  fail,  the  catheter  must  be  passed.  At  the  present  day 
it  is  hardly  necessary  to  insist  upon  the  fact  that  there  is  but  one 
manner  in  which  the  catheter  may  be  passed,  and  that  the  old 
method,  in  which  carefully  acquired  skill  was  used  to  pass  the 
catheter  under  the  bed-clothes,  is  so  incongruous  in  view  of  the 
elaborate  aseptic  precautions  which  are  taken  at  other  times,  that 
it  can  no  longer  be  adopted  by  anyone  capable  of  reasoning.  In 
all  cases  the  parts  must  be  exposed,  the  vulva,  especially  round 
the  orifice  of  the  urethra,  carefully  washed  with  an  antiseptic 
lotion  in  order  to  remove  all  discharge,  etc.,  and  the  catheter  then 
passed  under  the  guidance  of  the  eye  directly  into  the  urethra 
without  touching  the  surrounding  parts.  A  glass  or  metal  female 
catheter,  which  has  been  boiled  for  five  minutes,  should  be  used. 

The  use  of  the  catheter  must  not  be  continued  beyond  the 
second  day,  as,  in  the  first  place,  the  patient  may  get  into  a  habit 
which  will  be  difficult  to  break  her  off,  and,  in  the  second 
place,  the  risk  of  infecting  the  bladder  is  greater  after  the  second 
day  on  account  of  the  presence,  on  the  external  genitals,  of 
lochia,  which  may  be  decomposing,  and  all  traces  of  which  it  is 
difficult  to  remove.  By  this  time,  the  patient  may  be  allowed 
to  kneel  up  in  bed,  or  even  to  stand  by  the  side  of  the  bed,  and 
in  this  way  it  will  be  almost  always  possible  for  her  to  empty 
the  bladder  of  her  own  accord. 

The  Eectum. — Aperient  medicine  may  be  given  on  the  evening 
of  the  second  or  the  morning  of  the  third  day  after  delivery.  Its 
administration  is  required  in  almost  every  case,  for  the  reasons 
that  have  been  already  stated.  Castor-oil  is  the  most  commonly 
used  drug  and  possesses  certain  advantages,  but  it  is  very 
nauseating,  and,  consequently,  many  patients  cannot  take  it. 
As  a  substitute  may  be  given  Pulv.  Glycyrrhizas  Co.,  Cascara 
Sagrada,  Sulphate  or  Citrate  of  Magnesium,  or,  in  fact,  whatever 
purgative  the  patient  is  accustomed  to  take.  If  a  motion  does 
not  result,  a  soap  and  water  enema  may  be  administered.  A 
mild  aperient  must  also  be  administered  every  second  day  during 
the  puerperium,  if  the  bowels  do  not  act  without  it. 

The  Promotion  of  the  Functions  Peculiar  to  the 

Puerperium. 

The  functions  peculiar  to  the  puerperium  are  involution  and 
lactation.  They  are  both  to  a  considerable  extent  promoted  by 
proper  attention  to  diet  and  to  the  action  of  the  bladder  and 
bowels,  but  there  are  also  other  means  by  which  their  course  can 
be  favourably  affected  and  to  which  we  shall  now  refer. 


THE  MAINTENANCE  OF  UTERINE  ASEPSIS  459 

Uterine  Involution. — The  two  most  important  factors  in  the 
production  of  perfect  uterine  involution  are  the  proper  manage- 
ment of  the  third  stage  of  labour  and  the  maintenance  of  uterine 
asepsis.  The  former  has  been  already  discussed.  Its  importance 
consists  in  the  fact  that  a  well-managed  third  stage  means  that 
the  patient  commences  her  puerperium  with  an  empty  and  well- 
retracted  uterus,  and  that  thus  two  of  the  most  common  causes 
of  sub-involution  (insufficient  involution) — uterine  congestion 
and  the  presence  of  pieces  of  placenta  or  bloodclot — are  non- 
existent. 

The  maintenance  of  uterine  asepsis  is  even  more  important. 
At  the  commencement  of  the  puerperium  the  uterus  and 
vagina,  in  a  normal  patient  in  whom  no  examinations  have 
been  made  after  the  birth  of  the  child,  have  been  proved  to  be 
aseptic,  and,  accordingly,  in  all  cases  in  which  bacteria  are  subse- 
quently found  in  the  genital  canal  they  must  have  gained  admis- 
sion from  the  outside.  Septic  bacteria  will,  in  all  probability, 
only  gain  admission  on  septic  fingers  or  instruments  passed  into 
the  vagina,  but  saprophytic  bacteria,  or  some  of  the  many  non- 
pathogenic bacteria  which  are  frequently  found  in  the  lochia,  may 
gain  entrance  into  the  vagina  by  direct  extension  upwards  from 
a  nidus  in  decomposing  lochia  on  the  vulva  or  bedclothes. 
Accordingly,  we  see  that  if  the  vagina  is  to  be  kept  free,  not 
only  from  septic,  but  also  from  saprophytic  bacteria,  it  is  not 
sufficient  to  merely  refrain  from  vaginal  examinations  or  opera- 
tions, but  it  is  also  necessary  to  shield  the  vaginal  orifice  so  far  as 
possible  from  the  air  by  a  sterilised  dressing.  The  necessity  for 
the  latter  step  is  frequently  not  recognised  even  by  obstetricians 
who  attach  the  greatest  importance  to  vaginal  asepsis.  The 
■reason  of  its  necessity  is,  however,  obvious.  If  the  third  stage 
is  properly  managed,  and  the  complete  emptying  of  the  uterus 
is  obtained,  then,  even  if  saprophytic  bacteria  gain  entrance  to 
the  vagina,  it  is  not  a  matter  of  any  great  importance,  as  the 
only  pabulum  on  which  they  can  feed  is  the  lochia,  and,  as  this  is 
always  flowing  downwards  from  the  vagina,  bacteria  are  removed 
almost  as  rapidly  as  they  gain  admittance.  Consequently, 
obstetricians  have,  to  a  certain  extent,  fallen  into  the  habit  of 
considering  that  the  presence  of  saprophytes  in  the  vaginal  lochia 
is  a  matter  of  very  little  importance.  This  view  is  all  very  well 
so  long  as  a  case  is  quite  normal  and  the  emptying  of  the  uterus 
is  complete.  If,  however,  the  latter  is  not  the  case,  the  presence 
of  saprophytes  becomes  of  importance,  and  instead  of  the  gradual 
removal  of  the  placental  fragment,  or  piece  of  membrane,  by 
an  aseptic  degenerative  process,  the  retained  fragment  undergoes 
decomposition.  In  many  hospitals,  it  is  customary  to  apply 
napkins  for  the  first  twenty-four  hours,  and  then  to  leave  the 
vagina  uncovered  so  that  the  discharge  may  flow  away  on  to  the 
draw-sheet.  This  practice  is  infinitely  preferable  to  the  leaving 
of  an   unsterilised  napkin  in  contact  with  the  vulva  for  a  long 


460  THE  PHYSIOLOGY  OF  THE  PUERPERIUM 

time,  and  in  many  cases  it  may  give  most  satisfactory  results. 
We  consider,  however,  that  still  better  results  would  be  obtained 
by  the  use  of  a  constantly  changed  pad  of  absorbent  wool,  either 
sterilised  or  impregnated  with  some  antiseptic  of  sufficient 
strength  to  prevent  decomposition  of  the  lochia  which  soaks 
into  it.  The  genital  canal  after  delivery  is  to  all  intents  and 
purposes  an  open  wound,  and  must  be  treated  accordingly.  If 
a  drainage  tube  is  inserted  through  an  opening  into  the  peritoneal 
cavity,  no  one  would  think  for  a  moment  of  maintaining  that 
because  the  operation  of  inserting  the  tube  was  carried  out 
aseptically,  and  the  discharge  from  the  cavity  was  aseptic,  that 
the  tube  should  be  allowed  to  discharge  openly  on  to  unclean 
dressings.  The  immediate  result  of  such  a  course  would  be  that 
the  escaped  discharge  would  putrify  round  the  mouth  of  the  tube, 
and  that  the  putrefactive  organisms  would  extend  along  the  tube 
and  involve  any  dead  matter  they  came  across.  That  such 
a  course  does  not  more  frequently  occur  in  the  case  of  the 
genital  canal  is  due  to  the  absence  of  dead  matter  and  the  strong 
downward  current  of  the  lochia.  The  common-sense  mode  of 
treating  the  genital  wound — for  so  it  may  be  termed— consists, 
first,  in  interposing  some  substance  between  it  and  the  air  which 
will  receive  the  discharge  and  prevent  it  temporarily  from 
putrefying,  and  which  will,  at  the  same  time,  act  as  a  filter 
through  which  bacteria  cannot  pass  ;  and,  secondly,  in  changing 
this  dressing  and  cleansing  the  external  parts  with  sufficient 
frequency. 

We  have  already  drawn  attention  to  the  necessity  for  sterilising 
the  pad,  which  is  applied  after  labour  over  the  vulva,  by  soaking 
it  in  corrosive  sublimate  solution,  and  we  wish  now  to  insist  on  the 
necessity  for  adopting  the  same  course  throughout  the  puerperium.- 
A  dry  sterilised  pad  would  be  preferable  to  the  wet  corrosive 
pad,  but  the  former  is  rarely  obtainable  in  general  practice, 
although  there  is  no  reason  why  it  should  not  be  obtained  in 
hospital  practice.  This  pad  should  be  covered  with  a  protecting 
sheet  of  dry  absorbent  cotton-wool,  which  may,  if  wished,  be 
impregnated  by  some  antiseptic,  such  as  salicylic  or  boracic 
acid.  During  the  first  twenty-four  hours,  the  dressing  should  be 
changed  whenever  the  lochia  come  through  the  outer  wool,  after 
this  it  must  be  changed  at  least  twice,  and  by  preference  four 
times,  in  the  twenty-four  hours.  At  the  same  time,  the  vulva  and 
surrounding  skin  must  be  gently  washed  with  some  weak  anti- 
septic lotion,  preferably  lysol. 

The  necessity  for  vaginal  douching  during  the  puerperium  is 
almost  as  strongly  urged  by  some  authorities  as  it  is  denied  by 
others.  Galabin:;c  considers  that  fa  course  perfectly  free  from 
febrile  disturbances  throughout  the  puerperal  state  is  more 
common  when  regular  irrigation  is  employed.'  Dakinf  admits 
that,  in  view  of  the  results  of  some  lying-in  hospitals,  '  it  is 
*  Op.  cit.  t  Op.  cit. 


THE  USE  OF  VAGINAL  DOUCHING  461 

obvious  that  in  private  practice  douches  can  be  safely  omitted 
after  normal  deliveries,'  but  still,  a  little  further  on,  he  states  that 
a  weak  antiseptic  douche,  though  not  essential,  may  with  advan- 
tage be  given  once  a  day  if  not  twice.  Giles's  attitude  is  equally 
guarded.  He  first  states  that  in  '  hospital  practice  we  think  the 
douche  should  always  be  given,  whilst  in  private  practice  it  is 
sometimes  better  that  it  should  be  omitted,'  but  in  another  place 
he  states,  '  daily  douching  is  not  necessary  ;  it  is  quite  sufficient 
that  the  outside  parts  be  carefully  washed  and  dried.'*  Fothergill  i 
considers  douching  is  '  a  cleanly  and  comfortable  practice,  and 
does  no  harm  if  the  nurse  is  careful  to  secure  perfect  cleanliness.' 
An  entirely  opposite  opinion  is,  on  the  other  hand,  expressed  by 
others.  The  authorities  of  the  Rotunda  Hospital,  where  the 
practice  has  been  given  up  for  years,  unhesitatingly  condemn 
the  use  of  a  prophylactic  post-partum  douche,  and  to  Smyly  in 
particular  is  due  the  credit  of  having  led  to  its  almost  complete 
condemnation  so  far  as  the  Dublin  School  of  Midwifery  is  con- 
cerned. Similarly,  on  the  Continent,  Schaeffer;|:  states  that 
vaginal  douches  must  be  avoided  after  the  placenta  has  been 
delivered,  and  Ribemont-Dessaignes§  holds  a  similar  opinion, 
while,  in  America,  Jewett  considers  that,  if  the  discharge  becomes 
foetid,  antiseptic  douches  may  be  called  for.  We  have  already 
given  our  own  opinion  on  the  subject  of  prophylactic  douching.  It 
is  difficult  to  understand  how  anyone  can  be  found  to  still  support 
the  practice  in  view  of  what  is  known  of  the  bacteriology  of  the 
vagina,  of  the  sources  of  septic  as  opposed  to  saprophytic  infec- 
tion, of  the  results  obtained  in  the  case  of  tens  of  thousands  of 
patients  where  no  douching  has  been  performed,  and  of  the 
admitted  difficulty  of  ensuring  that  an  ordinary  nurse  will 
administer  a  douche  in  a  reasonably  safe  manner.  It  is  a 
curious  fact  that  many  of  those  who  sanction  this  practice  also 
allow  the  douche  to  be  administered  with  a  Higginson's  enema 
syringe,  and  recommend  the  use  of  corrosive  sublimate  solution — 
facts,  which,  we  think,  show  that  their  opinions  are  controlled 
more  by  a  well-rooted  conservatism  than  by  scientific  principles. 

So  far  as  the  doing  of  harm  is  concerned,  no  distinction  can  be 
drawn  for  the  first  four  or  five  days  between  a  vaginal  and  a 
uterine  douche,  inasmuch  as  some  of  the  fluid  will,  in  all  cases, 
find  its  way  into  the  uterus  even  though  the  nozzle  of  the  douche  is 
not  passed  beyond  the  vagina,  and  so  will  carry  infection  upwards 
if  there  is  any  to  be  carried.  So  far  as  the  doing  of  good,  on  the 
other  hand,  is  concerned,  there  is  a  difference,  inasmuch  as,  unless 
the  nozzle  is  carried  into  the  uterus,  the  current  will  not  be  suffi- 
cient to  wash  away  putrid  lochia  or  retained  clots.  Accordingly, 
in  the  first  four  days,  in  all  cases  in  which  a  douche  is  adminis- 

*  '  Encyc.  Medica,'  loc.  cit. 

t  '  A  Manual  of  Midwifery,'  second  edition,  p.  459. 

I   '  Obstetrical  Diagnosis  and  Treatment,'  American  edition,  p.  131. 

§  '  Precis  d'Obstetriques,'  p.  549. 


462  THE  PHYSIOLOGY  OF  THE  PUERPERIUM 

tered,  the  nozzle  of  the  tube  is,  perhaps,  best  passed  into  the 
uterus.  After  that  time  a  distinction  may  be  made,  and  a  vaginal 
or  a  vaginal  and  uterine  douche  administered  as  is  thought  best. 

Douching  during  the  puerperium  is  indicated  under  certain 
definite  conditions  : — 

(i)  If  the  lochia  become  foetid  and  the  condition  is  not  removed 
within  twelve  hours  by  other  means. 

(2)  If  the  involution  of  the  uterus  does  not  follow  its  normal 
course.  In  these  cases  a  hot  douche  will  stimulate  contraction 
of  the  uterus  and  so  encourage  involution. 

(3)  If  there  is  secondary  post-partum  haemorrhage. 

The  method  of  administering  a  douche  and  the  antiseptics 
which  are  suitable  have  been  already  mentioned. 

Another  important  factor  in  the  production  of  involution  is 
rest  in  the  recumbent  position.  Sub-involution  is  a  much  more 
common  occurrence  amongst  the  poorer  classes,  who  return  to 
their  work  before  involution  has  reached  a  proper  stage,  than 
amongst  the  well-to-do  classes.  It  is,  of  course,  neither  necessary 
nor  advisable  that  the  patient  should  remain  in  bed  until  involu- 
tion is  complete,  but  she  should  do  so  until  all  lacerations  have 
healed,  until  the  uterus  has  descended  again  into  the  pelvic  cavity, 
and  until  the  lochia  have  become  colourless  and  have  almost  or 
completely  ceased.  As  a  general  rule,  these  conditions  are  ful- 
filled about  the  tenth  or  twelfth  day,  and,  save  in  exceptional 
cases,  it  is  not  necessary  that  the  patient  should  remain  longer 
than  this  in  bed.  She  need  not,  however,  maintain  the  recumbent 
position  during  the  entire  period.  After  the  third  or  fourth 
day,  if  feeling  well,  and  if  the  perinaeum  has  not  been  sutured, 
she  may  be  propped  up  in  bed  by  means  of  a  few  pillows  for 
a  short  time,  and,  after  the  sixth  day,  she  may  similarly  sit  up  in 
bed  without  support.  In  this  way  the  tedium  of  convalescence 
will  be  rendered  less,  and  by  the  promotion  of  vaginal  drainage 
involution  will  be  encouraged. 

Lactation. — The  treatment  of  the  breasts  differs  according  as 
the  mother  decides  to  nurse  the  infant  or  not  to  do  so.  In  cases 
in  which  she  decides  to  nurse,  the  initial  preparation  of  the  nipple 
has  been  described.  As  soon  as  she  is  rested  after  the  completion 
of  delivery,  the  infant  may  be  put  to  the  breast,  with  the  object 
of  stimulating  lactation,  of  promoting  contraction  of  the  uterus, 
and  of  allowing  the  infant  to  get  the  benefit  of  the  colostrum. 
From  this  on,  until  lactation  is  established,  the  infant  may  be  put 
to  the  breast  every  four  hours.  As  soon  as  lactation  is  established 
a  regular  interval  of  two  hours  is  allowed  between  each  feeding, 
with  the  exception  of  one  interval  of  four  to  five  hours  at  night. 
In  all  cases,  the  nipples  must  be  washed  with  a  little  warm  water 
before  and  after  each  nursing.  The  first  washing  is  performed 
in  order  to  remove  any  milk  which  may  have  dried  on  the  nipple 
and  which,  being  sour,  would  produce  a  bad  effect  upon  the  child. 
The  second  washing  is  performed  in  order  to  remove  the  remains 


THE  MANAGEMENT  OF  LACTATING  BREASTS  463 

of  all  milk  from  the  nipple,  and  so  to  prevent,  as  far  as  possible, 
milk  decomposing  there  and  leading  to  the  infection  of  the  milk 
glands  and  ducts. 

If  the  nipples  become  cracked  owing  to  the  tender  condition 
of  the  skin,  the  crack  may  be  lightly  touched  with  nitrate  of 
silver  or  painted  twice  a  day  with  a  little  Tinct.  Benzoin.  Co.  If 
the  crack  renders  the  act  of  nursing  painful,  a  nipple  shield  may 
be  placed  over  the  nipple  and  the  child  allowed  to  suck  through 
it.  A  little  lanoline  rubbed  into  the  base  of  the  nipple  each  day 
will  render  the  skin  elastic  and  help  to  close  up  any  cracks,  and 
for  this  reason  is  said  to  be  better  than  the  usual  hardening  agents, 
such  as  alcohol.  When  all  cracks  are  healed  the  shield  may  be 
dispensed  with. 

If  the  breasts  become  knotted,  tense,  and  tender,  considerable 
relief  will  be  obtained  by  the  application  of  what  is  known  as 
a  cere-cloth — that  is  to  say,  of  a  piece  of  lint  covered  with  cere 
ointment,  a  preparation  consisting  of  one  part  of  yellow  wax  and 
eight  parts  of  olive  oil.  If  the  nipples  are  so  depressed  that  the 
infant  cannot  seize  them,  a  nipple  shield  must  be  used.  If  the 
breasts  are  swollen  and  distended  and  tend  to  fall  unduly  to  one 
or  other  side  owing  to  their  weight,  a  breast  bandage  so  applied 
as  to  maintain  them  in  their  proper  position  will  give  considerable 
relief.  A  saline  purgative  may  also  be  administered.  If  the 
amount  of  milk  is  insufficient,  it  may  be  indirectly  increased  by 
'  over-feeding '  the  mother — that  is,  by  inducing  her  to  take 
a  greater  proportion  of  nourishment  than  she  is  actually  in- 
clined for  or  than  would  be  natural  under  other  circumstances. 
Care  must  be,  however,  taken  that  the  digestion  is  not  inter- 
fered with.  The  administration  of  some  of  the  various  milk 
derivatives — such  as  somatose  and  plasmon — may  also  produce 
a  good  effect. 

If  the  mother  does  not  intend  to  nurse  the  infant,  the  necessary 
steps  for  preventing  the  establishment  of  lactation  must  be  taken 
as  soon  after  the  completion  of  labour  as  possible.  The  first  step 
consists  in  refraining  from  any  procedure  which  tends  to  stimulate 
the  secretion  of  milk,  such  as  drawing  out  the  nipple  or  putting 
the  baby  to  the  breast.  Then,  as  soon  as  the  patient  is  rested, 
a  pad  of  cotton- wool  .may  be  applied  over  each  breast  and  kept 
in  place  by  a  bandage  so  applied  as  to  exert  gentle  elastic 
pressure  upon  the  breast.  It  is  customary  to  apply  to  the 
breast  some  application  which  is  reputed  to  check  the  secre- 
tion of  milk,  and  that  usually  adopted  is  glycerine  of  belladonna 
(Ext.  Belladonnae,  grs.  lx.  ;  Glycerine,  §i.)  which  is  painted  over 
the  breast.  Rubbing  is  contra-indicated,  as  it  tends  to  encourage 
the  activity  of  the  gland.  A  substitute  for  belladonna  is  to  be 
found  in  the  cere  ointment,  to  which  we  have  already  referred. 
It  is  the  anti-galactogogue  which  has  been  adopted  at  the 
Rotunda  Hospital  for  a  considerable  time,  and  it  is,  to  our 
mind,  as  satisfactory  as  belladonna  and  safer  for  use  in  general 


464  THE  PHYSIOLOGY  OF  THE  PUERPERIUM 

practice.  In  addition  to  compression  of  the  breast  and  the 
application  of  an  anti-galactogogue,  a  brisk  saline  purge  should 
be  administered  on  the  morning  of  the  second  day  or  even  before 
this  if  the  patient's  condition  does  not  contra-indicate  it.  The 
internal  administration  of  iodide  of  potassium  has  also  been 
recommended  in  these  cases  on  account  of  its  action  in  checking 
gland  secretion.  It  may  be  given  in  doses  of  twenty  grains,  if  it 
is  required,  but  this  is  rarely  the  case. 

If  the  breasts  become  very  tender  and  tense,  a  small  quantity 
of  milk,  sufficient  to  diminish  the  tension,  may  be  drawn  off  with 
a  breast-pump,  but,  as  this  procedure  tends  to  stimulate  the 
activity  of  the  gland,  it  should  not  be  adopted  unless  the  discom- 
fort of  the  patient  renders  it  necessary.  If  belladonna  is  applied 
to  the  breast,  the  infant  should  not  under  any  circumstances  be 
allowed  to  suckle,  as  the  toxic  effects  of  belladonna  upon  young 
infants  are  considerable. 

In  all  cases  in  which  the  mother  is  healthy  she  should,  if 
possible,  nurse  the  infant.  If  it  is  subsequently  found  that  her 
milk  is  either  insufficient  in  quantity  or  unsuitable  in  quality  she 
may  have  to  stop  doing  so,  but,  as  it  is  impossible  to  foretell 
this,  she  should,  in  all  cases,  try  to  nurse.  The  conditions  which 
render  it  inadvisable  that  she  should  nurse  may  be  divided  into 
two  classes.  She  should  not  nurse  the  infant  for  her  own  sake,  if 
she  is  in  an  enfeebled  condition  owing  to  previous  haemorrhages, 
phthisis,  anaemia,  or  during  convalescence  from  any  acute 
disease.  She  should  not  nurse  the  infant  for  its  sake,  if  she  is 
suffering  from  syphilis,  if  her  milk  is  of  poor  quality,  or  if  the 
breasts  are  inflamed.  In  cases  of  phthisis,  or  during  acute  fevers, 
nursing  is  also  contra-indicated  for  the  sake  of  the  infant. 

General  Points. — There  are  a  few  remaining  points  in  the 
management  of  the  puerperium  which  do  not  come  under  either 
of  the  foregoing  headings  and  which  we  will  now  briefly  refer  to. 

Sleep. — Plenty  of  sleep  is  of  the  first  importance  during  the 
puerperium  in  order  that  the  patient  may  recover  from  the 
mental  and  physical  exhaustion  from  which  she  suffers.  Nature 
thoroughly  recognises  this  fact,  and  it  is  but  rarely  indeed  that 
a  puerperal  woman  does  not  sleep  sufficiently,  unless  there  is 
some  condition  present  which  prevents  her.  from  doing  so.  Sleep- 
lessness, in  the  absence  of  pain,  is  a  serious  symptom,  and  is 
most  usually  caused  by  septic  infection,  or  by  some  threatening 
mental  derangement.  If  the  patient  does  not  sleep,  every  effort 
must  be  made  to  determine  the  cause,  and  if  the  sleeplessness 
persists,  it  may  be  necessary  to  obtain  sleep  by  the  administration 
of  a  hypnotic,  such  as  sulphonal  or  bromidia.  The  use  of  opium 
is  contra-indicated,  if  the  patient  is  nursing,  save  in  very  small 
doses. 

After-pains. — The  common  cause  of  severe  after-pains  is,  as  has 
been  mentioned,  the  presence  of  a  clot  of  blood  in  the  uterus,  and, 
consequently,  the  most  satisfactory  method  of  getting  rid  of  the 


THE  COMPLICATIONS  OF  THE  PUERPERIUM  465 

pains  consists  in  expelling  the  clot.  To  do  this  gentle  massage 
and  compression  of  the  uterus  is  usually  sufficient,  but  in  some 
cases  a  uterine  douche  may  be  required.  The  application  of 
a  hot  compress  over  the  lower  portion  of  the  abdomen  may  also 
give  relief.  If  the  patient  is  not  nursing  and  the  after-pains  are 
very  severe,  twenty  to  thirty  minims  of  Tincture  of  Opium  may 
be  given,  while  if  she  is  nursing  a  draught  containing  ten  to 
twenty  grains  of  chloral  hydrate,  or  if  there  is  much  mental 
excitability  half  a  drachm  to  one  drachm  of  Tincture  of  Hyo- 
scyamus  may  be  substituted. 

Medical  Visits. — The  obstetrician  should,  in  all  cases,  see  the 
patient  within  eighteen  hours  of  her  confinement  in  order  that  he 
may  satisfy  himself  as  to  the  emptying  of  the  bladder,  the  amount 
of  discharge,  and  the  general  manner  in  which  the  patient  is 
recovering  from  the  effects  of  labour.  Subsequently,  he  should 
visit  the  patient  at  least  once  a  day  for  the  first  three  days,  and 
then  every  second  day  until  the  tenth  or  twelfth  day.  If  her 
symptoms  are  not  satisfactory  she  must  be  seen  every  day,  or, 
perhaps,  in  some  cases,  even  twice  a  day.  At  the  time  of  his 
visit  he  must  note  the  following  points  concerning  the  mother  : — 
The  temperature,  the  pulse-rate,  the  aspect,  the  amount  of  sleep 
she  has  had  since  the  last  visit,  the  condition  of  the  bowels  and 
bladder,  the  height  of  the  uterus,  the  condition  of  the  breasts 
and  the  amount  of  milk,  the  nature  of  the  appetite,  the  character 
and  amount  of  the  lochia.  He  must  also  ascertain  the  following 
points  regarding  the  infant  : — Its  appearance,  the  condition  of  the 
bladder  and  bowels,  the  nature  of  its  appetite  and  powers  of 
sucking,  and  the  presence  of  any  abnormalities  of  development 
which  may  have  escaped  notice  at  birth,  or  of  any  pathological 
condition  which  may  have  occurred  since.  When  we  know  that 
the  nurse  in  attendance  has  been  properly  trained  and  that  we 
can  rely  upon  her,  it  is  not  necessary  to  enter  into  all  these  points 
in  detail,  as  the  simple  question,  '  How  is  the  patient  ?'  should 
be  sufficient  to  elicit  from  her  any  symptoms  or  conditions  of 
importance  which  she  has  noticed. 

Prognosis. — We  can  determine  whether  the  patient  is  progressing 
favourably  or  the  reverse  by  the  information  we  obtain  on  the 
foregoing  points.  The  most  important  of  these  are  the  condition 
of  the  pulse  and  temperature,  the  aspect,  the  amount  of  sleep, 
and  the  character  of  the  lochia,  and  if  they  are  found  to  be 
normal  we  may  safely  consider  that  the  course  of  the  puerperium 
is  satisfactory.  Complications,  for  the  symptoms  of  which  we 
must  specially  watch,  are  septic  infection  or  saprophytic  intoxica- 
tion, secondary  haemorrhage,  mastitis,  crural  phlegmasia^  and  any 
form  of  mental  derangement.  The  less  serious  complications 
are  retention  of  urine,  constipation,  cracked  nipples,  and  sub- 
involution. 


3° 


PART  VI 
THE    PATHOLOGY   OF    PREGNANCY 


30—2 


CHAPTER  I 
THE  DISORDERS  OF  PREGNANCY 

Disorders  of  the  Digestive  System — Nausea  and  Vomiting — Constipation. 
Disorders  of  the  Urinary  System— Retention  of  Urine — Incontinence  of 
Urine  and  Bladder  Irritability.  Disorders  of  the  Vascular  System — 
Haemorrhoids  and  Varicose  Veins — Anaemia — Hydrsemia.  Disorders  of 
the  Nervous  System — Neuralgia — Insomnia — Longings. 

Under  the  heading  '  the  disorders  of  pregnancy,'  we  propose  to 
include  such  temporary  systemic  disturbances  of  slight  degree  as 
may  arise  during  pregnancy  as  a  result  of  the  altered  nutrition, 
the  nervous  exaltation,  and  the  anatomical  changes  by  which  this 
condition  is  accompanied.  These  disorders  may  be  conveniently 
arranged  in  groups  according  as  they  affect  the  digestive  organs, 
the  urinary  organs,  the  vascular  system,  or  the  nervous  system. 

DISORDERS  OF  THE  DIGESTIVE  SYSTEM 

Nausea  and  Vomiting. — The  occurrence  of  nausea  and  vomit- 
ing during  the  early  months  of  pregnancy  is  of  such  common 
occurrence  that  it  has  been  already  referred  to  as  one  of  the  sub- 
jective symptoms  of  pregnancy,  and  may  be  considered  to  be 
physiological  so  long  as  it  is  slight  in  degree  and  limited  to  one 
period  of  the  day.  The  older  writers,  indeed,  considered  it  to  be  not 
only  physiological,  but  even  advantageous  to  the  pregnant  woman, 
and  one  of  them  states  that  when  '  vomiting  is  entirely  absent, 
utero-gestation  does  not  proceed  with  its  usual  regularity  and 
activity'  (Ramsbotham*),  an  opinion  which  was  shared  by  others. 
As  the  nausea  usually  comes  on  when  the  woman  commences  to 
move  from  the  recumbent  position  in  the  morning,  and  either 
before  or  shortly  after  leaving  her  bed,  it  is  usually  known  as 
morning  sickness.  This  condition  must  be  carefully  distinguished 
from  one  in  which  vomiting  occurs  after  taking  food,  and  is  so 
persistent  as  to  interfere  with  the  nutrition  of  the  patient.  The 
latter  condition  is  a  serious  one  and  will  be  referred  to  later  under 
the  head  of  '  Hyperemesis.' 

*  'Practical  Observations  on  Midwifery,'  part  ii. ,  p.  366. 
469 


470  THE  PATHOLOGY  OF  PREGNANCY 

JEtiology. — The  causation  of  morning  sickness  is  obscure. 
Rheinstadter*  advanced  the  hypothesis  that  it  is  due  to  the 
movements  of  an  enlarged  uterus  amongst  the  intestines,  but 
inasmuch  as  it  occurs  at  a  period  when  uterine  enlargement  is 
little  marked,  and  as  it  passes  off  when  the  enlargement  might 
reasonably  be  expected  to  produce  some  intestinal  compression 
or  irritation,  this  explanation  seems  hardly  probable.  A  more 
probable  explanation  is,  perhaps,  to  be  found  in  considering  the 
phenomenon  to  be  due  to  the  unstable  condition  of  the  nerve 
centres  in  pregnancy,  as  a  result  of  which  they  respond  to  stimuli 
which,  under  other  circumstances,  would  not  affect  them.  The 
fact  that  the  sickness  most  usually  occurs  in  the  morning  can  be 
explained  by  the  change  in  the  position  of  the  patient  at  that 
time  and  by  the  fact  that  '  the  nerves  are,  as  it  were,  then  first 
roused  from  their  slumber  and  are  alive  to  impressions  which 
produce  no  effect  during  sleep ;  hence  the  irritation  of  the 
stomach,  like  the  irritation  of  the  bladder,  is  felt  as  soon  as  the 
patient  wakes  from  sleep'  (Murphyt). 

Symptoms. — Morning  sickness  most  usually  commences  about 
the  sixth  week  and  passes  off  about  the  end  of  the  second  month. 
Occasionally,  it  may  commence  earlier  or  persist  until  the  end 
of  the  fourth  month.  The  nausea  commonly  starts  as  soon  as 
the  woman  commences  to  move  from  a  recumbent  position,  or, 
perhaps,  after  she  has  left  her  bed.  In  some  cases  there  may  be 
only  nausea,  but,  as  a  rule,  vomiting  follows,  after  which  the 
woman  feels  considerably  relieved  and  is  well  for  the  remainder 
of  the  day.  The  vomited  matter  consists  of  mucus,  sometimes 
very  acid  in  reaction,  and  at  other  times  neutral. 

In  cases  in  which  the  sickness  is  more  marked,  nausea  and 
occasional  attacks  of  vomiting  may  persist  for  several  hours,  after 
which  the  patient  obtains  relief.  Such  cases  are,  however,  on  the 
borderland  of  hyperemesis,  and  must  be  carefully  watched  and 
treated,  as,  if  neglected,  the  border-line  may  be  passed. 

Treatment. — Simple  morning  sickness  requires  little  or  no 
treatment.  Indeed,  in  many  cases,  the  patient  is  ill  and  well 
again  before  any  treatment  can  be  carried  out.  As  the  empty 
condition  of  the  stomach,  perhaps,  aggravates  the  sickness  the 
most  sensible  line  of  treatment  consists  in  the  patient  taking 
a  small  cup  of  tea  and  a  piece  of  dry  toast,  or  a  cup  of  bread  and 
milk,  before  sitting  up  in  bed  in  the  morning.  This,  in  associa- 
tion with  the  regulation  of  the  bowels,  usually  is  all  that  is 
required.  If  the  sickness  persists  after  the  patient  rises,  the 
administration  of  hydrocyanic  acid,  of  bismuth,  of  bicarbonate  of 
soda,  or  of  any  of  the  ordinary  anti-emetic  drugs,  may  be  tried. 
A  large  draught  of  hot  water,  which  if  brought  back  will  wash 
out  the  stomach,  is  also  useful.  In  such  cases  it  is  well  for  the 
woman  to  remain  in  bed  until  the  tendency  to  sickness  has  passed 

*  Zweifel's  '  Lehrbuch  der  Geburtschiilfe,'  1887,  p.  269. 

t  '  Principles  and  Practice  of  Midwifery,'  second  edition,  p.  51. 


CONSTIPATION  <tfi 

off,   as   the   active    movement    of   dressing,  etc.,  aggravates  the 
condition. 

Constipation. — Constipation  is  of  very  common  occurrence  in 
pregnancy,  and  if  allowed  to  persist  may  lead  to  far-reaching 
ill  results  to  both  mother  and  foetus.  The  importance  of  the 
regular  action  of  the  bowels  is  considerable  at  all  times,  but 
during  pregnancy  it  is  even  more  marked,  as  the  waste  products 
of  both  the  mother  and  foetus  have  to  be  then  eliminated  through 
the  maternal  system,  and  as  the  proper  functionating  of  the  other 
eliminatory  organs  is  dependent  to  a  considerable  extent  upon 
that  of  the  bowels. 

Two  subsidiary  conditions  are  often  found  in  association  with 
constipation,  and  may  give  rise  to  considerable  discomfort ;  these 
are  pyrosis  or  heart-burn,  and  flatulence.  Pyrosis  is  the  result  of 
imperfect  digestion  of  food,  and  though  not  actually  caused  by 
constipation  is  considerably  aggravated  by  this  condition.  Flatu- 
lence is  usually  due  to  abnormal  decomposition  of  food  in 
the  intestines,  a  process  which  is  necessarily  promoted  by  con- 
stipation. 

Treatment. — If  possible,  we  should  always  endeavour  to  relieve 
constipation  by  alterations  in  the  patient's  dietary  and  general 
mode  of  life,  rather  than  by  the  administration  of  drugs.  If,  how- 
ever, it  is  found  to  be  impossible  to  regulate  the  bowels  by  such 
means,  laxatives  must  be  resorted  to  or  the  use  of  enemata,  and 
as  a  last  resource  purgatives  must  be  administered.  It  is  best  to 
avoid  the  use  of  the  latter  during  pregnancy  if  possible,  but  if  the 
necessary  movements  of  the  bowels  cannot  be  obtained  by  other 
means,  their  use  is  indicated,  as  on  no  account  must  a  condition 
of  constipation  be  allowed  to  persist.  The  dietetic  treatment  of 
constipation  consists  in  the  main  in  the  use  of  such  foods  as  leave 
in  the  intestine  a  considerable  amount  of  undigested  residue  which, 
by  its  presence,  causes  a  mechanical  irritation  of  the  intestinal 
mucous  membrane.  Such  foods  are  green  vegetables,  whole-meal 
bread,  stewed  dry  fruits  or  ripe  fruits,  salads,  and  fresh  fruit  jams 
and  preserves.  A  common  cause  of  constipation  during  preg- 
nancy is  an  insufficient  consumption  of  fluids,  leading  to  a  diminu- 
tion in  the  fluid  part  of  the  intestinal  secretions  and  a  consequent 
dryness  of  the  intestinal  contents.  In  order  to  counteract  this 
the  free  consumption  of  fluids,  especially  water,  is  advisable.  In 
many  cases  of  constipation  great  benefit  is  derived  from  good 
draughts  of  water  before  going  to  bed  and  in  the  morning  while 
still  fasting.  Similarly,  plenty  of  fluid  may  be  consumed  through 
the  day,  provided  that  it  is  not  taken  in  such  a  manner  as  to 
interfere  with  the  appetite. 

If  laxatives  are  required,  perhaps  the  best  form  in  which  to 
administer  them  is  as  some  of  the  natural  saline  mineral  waters, 
such  as  Apenta,  or  Hunyadi  Janos  water.  Either  of  these  may 
be  given  as  a  routine  every  morning  on  an  empty  stomach  in 


472  THE  PATHOLOGY  OF  PREGNANCY 

quantities  of  half  a  wineglass  to  two  wineglasses.  If  their  use  is 
not  sufficient,  a  water  or  a  soap  and  water  enema  may  be  given, 
when  necessary,  in  the  case  of  patients  who  are  not  upset  by  it — as 
some  are  prone  to  be.  Other  laxatives  which  may  be  found  of  value 
in  particular  cases  are  Tamar  Indien,  small  doses  of  Castor  Oil 
(3i.  to  5iii.),  Sulphate  of  Magnesium  (7)\  to  gi.),  Cascara  Sagrada 
(3ss.  of  the  Liquid  Extract),  Calomel  (gr.  ss.  to  gr.  i.  repeated), 
or  compound  liquorice  powder  (3ss.).  If  such  doses  are  not 
sufficient,  the  drugs  must  be  given  in  purgative  doses.  The 
best  method  of  relieving  pyrosis  is  by  promoting  digestion, 
by  giving  suitable  and  easily  digested  food,  and  by  the  use  of 
carminatives.  If  the  gastric  secretions  do  not  appear  to  be 
capable  of  discharging  their  function,  it  may  be  necessary  to 
administer  adjuvants,  such  as  one  of  the  many  preparations 
of  pepsine,  or,  in  rare  cases,  to  feed  the  patient  on  partially 
pre-digested  foods.  Excessive  flatulence  will  be  best  relieved 
by  the  administration  of  creosote  and  by  avoiding  all  foods 
which  tend  to  promote  fermentation.  As  foods  which  leave 
a  large  undigested  residue  tend  to  promote  fermentation  it  will 
usually  be  impossible  to  carry  out  the  dietetic  treatment  of  con- 
stipation by  their  aid  in  cases  in  which  the  patient  suffers  much 
from  either  pyrosis  or  flatulence,  and,  consequently,  other  means 
must  be  adopted.  As  an  alternative  to  creosote,  Dakin  recom- 
mends the  administration  of  sulpho-carbolate  of  soda  from  three- 
quarters  of  an  hour  to  one  hour  after  meals.  A  small  dose  of 
a  pepsin  preparation,  taken  during  meals,  is  also  of  use. 

Salivation. — Profuse  salivation,  or  ptyalism,  is  a  rare  con- 
comitant of  pregnancy.  In  some  cases,  very  large  quantities  of 
thin  saliva  are  secreted,  as  much  as  a  quart,  or  even  more,  coming 
away  in  the  twenty-four  hours.  It  is  a  most  distressing  condition 
as,  in  bad  cases,  it  necessitates  the  patient  continually  catching 
the  saliva  as  it  dribbles  from  the  mouth.  Occasionally,  there  is 
an  accompanying  swollen  and  painful  condition  of  the  sub-maxillary 
and  parotid  glands. 

Treatment.— -Probably  the  only  drug  which  will  be  found  to  pro- 
duce any  effect  is  atropine.  It  may  be  given  in  two  to  four  minim 
doses  of  the  Liquor.  It  is  also  recommended  to  wash  out  the 
mouth  with  astringent  gargles,  but  it  is  difficult  to  see  how 
such  a  process  can  affect  the  condition.  The  administration  of 
potassium  bromide  has  been  tried  with  success  (Dakin*). 

*  Op.  tit.,  p.  2S6. 


RETENTION  OF  URINE  473 


DISORDERS  OF  THE  URINARY  SYSTEM 

The  various  forms  of  renal  disease  which  may  be  met  with 
during  pregnancy  are  of  too  great  importance  to  be  treated  of  in 
the  present  chapter,  and,  consequently,  we  shall  here  only  refer  to 
such  conditions  of  the  bladder  as  may  be  the  temporary  results  of 
pregnancy  and  may  give  rise  to  interference  with  the  normal 
functions  of  this  viscus. 

Retention  of  Urine. — Retention  of  urine  is  a  serious,  but 
uncommon  occurrence  during  pregnancy. 

Aitiology. — It  is  practically  confined  to  cases  in  which  a  dis- 
placement of  either  the  uterus  or  vagina  brings  about  a  mechanical 
interference  with  the  normal  relations  of  the  neck  of  the  bladder 
or  urethra.  The  two  most  common  conditions  which  act  in  this 
manner  are  retro-deviation  of  the  uterus  and  prolapse  of  the  uterus 
or  of  the  anterior  vaginal  wall.  As  each  of  these  conditions  will 
be  subsequently  referred  to,  it  is  unnecessary  here  to  say  more 
regarding  the  manner  in  which  they  cause  retention,  than  that 
retention  is  caused,  in  retro-deviation  of  the  uterus,  by  direct  com- 
pression of  the  neck  of  the  bladder  between  the  enlarged  uterus 
and  the  back  of  the  symphysis,  and,  in  prolapse  of  either  the 
uterus  or  the  vagina,  by  the  displacement  downward  of  the  bladder 
leading  to  kinking  of  the  urethra. 

Symptoms. — The  first  symptoms  caused  by  retention  are  too 
well  known  to  need  mention  ;  when,  however,  the  bladder  becomes 
much  over-distended  the  symptoms  alter,  and  so  sometimes  give 
rise  to  confusion.  Such  a  degree  of  over-distension  can  only  occur 
in  cases  in  which  the  bladder  has  become  an  abdominal  organ,  as 
is  the  case  in  retention  due  to  retro-deviation  of  the  uterus.  In 
these  cases,  the  most  urgent  symptom  of  the  patient  is  intense 
pain,  referred  not  only  to  the  bladder,  but  to  the  pelvis  generally. 
The  pelvic  pain  is  due  to  the  pressure  of  the  enlarged  uterus, 
and  serves  to  some  extent  to  mask  the  nature  of  the  case.  The 
initial  desire  to  empty  the  bladder  may  completely  pass  away, 
and  be  replaced  by  the  fancy  that  there  is  no  water  in  the  bladder. 
This  notion  is,  to  a  great  extent,  due  to  the  fact  that  the  urine 
dribbles  away  involuntarily  from  the  over-distended  bladder  and 
that,  consequently,  the  patient  considers  that  '  she  is  emptying  the 
bladder  every  few  minutes.'  To  this  condition  of  incontinence, 
due  to  over-distension,  the  term,  ischuria  paradoxa  has  been 
applied. 

Diagnosis. — The  diagnosis  of  distension  of  the  bladder  can  be 
made  by  palpating  the  distended  bladder  in  a  case  of  considerable 
distension,  or,  in  a  case  of  slighter  distension,  by  mapping  out  the 
outline  of  the  bladder  by  percussion.  An  over-distended  bladder 
must  be  distinguished  from  an  enlarged  uterus  or  other  tumour. 
This  can  be  done  from  the  history  of  the  case  and  from  the  results 


474  THE  PATHOLOGY  OF  PREGNANCY 

of  a  bi-manual  or  vaginal  examination.  In  retention  due  to 
uterine  prolapse,  the  distended  bladder  will  be  found  in  the  pelvic 
cavity.  These  cases  do  not,  however,  give  rise  to  considerable 
degrees  of  distension,  as,  in  all  probability,  as  the  bladder  fills  it 
rises  in  the  pelvis  sufficiently  to  straighten  out  the  kinked  urethra. 
Treatment. — In  cases  due  to  prolapse,  there  is  usually  no  difficulty 
in  passing  a  catheter  and  drawing  off  the  urine.  The  prolapse 
must  then  be  suitably  treated  in  order  to  prevent  a  return  of  the 
retention.  In  cases  of  retention,  due  to  retro-deviation  of  the 
uterus,  it  is  often  most  difficult  to  empty  the  bladder.  The  causes 
of  this  are  to  be  found  in  the  upward  displacement  of  the  orifice 
of  the  urethra,  which  is  brought  about  by  the  mal-position  of  the 
uterus,  and  which  may  render  it  difficult  or  impossible  to  pass  a 
catheter  into  the  orifice  ;  in  the  compression  of  the  urethra  by  the 
enlarged  uterus  ;  and,  even  after  the  catheter  has  reached  the 
interior  of  the  bladder,  in  the  blockage  of  its  eye  by  detached 
pieces  of  vesical  mucous  membrane.  If  the  ordinary  metal 
female  catheter  cannot  be  passed  in  these  cases,  a  male  gum-elastic 
catheter  must  be  tried,  and  it  will  sometimes  be  possible  to  pass 
this  when  the  other  has  failed.  Barnes*  recommends  that  '  the 
point  of  the  catheter,  instead  of  being  directed  a  little  backwards 
under  the  pubic  arch,  be  directed  close  up  behind  the  symphysis.  .  .  . 
It  should,  in  the  first  instance,  be  passed  in  as  far  as  it  will  go, 
and  then,  when  the  urine  ceases  to  flow,  withdrawn  by  slow 
degrees,  when  more  urine  will  often  flow  as  if  the  catheter  tapped 
fresh  pouches  of  the  bladder.'  If  the  attempt  at  introduction 
proves  unsuccessful,  the  patient  must  be  placed  in  the  knee-chest 
position  and  an  attempt  again  made  with  a  gum-elastic  catheter. 
Sometimes,  it  may  be  possible  to  lessen  the  pressure  upon  the 
urethra  by  introducing  a  finger  into  the  vagina  and  pressing  the 
cervix  backwards.  If  even  this  attempt  fails,  there  is  usually 
nothing  for  it  but  to  puncture  the  bladder  supra-pubically  and  to 
draw  off  the  urine.  In  such  cases,  the  needle  of  the  aspirator  is 
introduced  about  two  inches  above  the  symphysis  in  the  middle 
line. 

Incontinence  of  Urine  and  Bladder  Irritability. — Slight 
incontinence  of  urine,  leading  to  the  escape  of  water  during 
the  act  of  coughing  or  straining,  is  not  an  infrequent  condition, 
especially  amongst  multipara?.  Irritability  of  the  bladder  is  also 
a  common  condition,  especially  in  the  early  months. 

Causes. — Incontinence  during  pregnancy  is  caused  by  a  relaxed 
condition  of  the  sphincter,  due,  perhaps,  to  stretching  and  com- 
pression of  the  neck  of  the  bladder  during  a  previous  pregnancy, 
plus  the  increased  intra-abdominal  pressure,  which  is  the  result 
of  the  enlarged  uterus.  Irritability  of  the  bladder  is  the  result  of 
the  increased  pressure  to  which  the  latter  is  subject,  and  is  most 
marked  when  the  uterus  is  a  pelvic  organ — i.e.,  up  to  the  end 
*  '  Obstetric  Operations,'  third  edition,  p.  273. 


HEMORRHOIDS  475 

of  the  fourth  or  fifth  month.  After  this  time,  the  uterus  rises 
into  the  abdomen,  and  almost  all  its  weight  is  taken  by  the 
abdominal  walls  and  iliac  bones ;  consequently,  there  is  at  once 
more  room  for  the  bladder  to  expand,  and  less  pressure  upon  it. 

Treatment. — Little  can  be  done  for  the  relief  of  incontinence 
during  pregnancy.  If  it  occurs,  the  patient  must  be  warned  of 
the  importance  of  keeping  the  parts  as  dry  and  free  from  urine 
as  possible,  as  otherwise  an  unpleasant  erythema  results.  An 
ointment  rubbed  on  the  parts  will  prevent  the  urine  from  coming 
into  contact  with  them.  Irritability  may  be  alleviated  by  the 
administration  of  Tincture  of  Hyoscyamus,  and  at  the  same  time 
the  patient  ought  to  be  advised  to  refrain  from  drinking  excessive 
quantities  of  fluid,  particularly  such  forms  as  she  finds  by 
experience  have  a  diuretic  effect.  In  irritability  occurring  during 
the  first  half  of  pregnancy,  it  is  usually  safe  to  promise  that  the 
condition  will  pass  off  in  a  little  time. 


DISORDERS  OF  THE  VASCULAR  SYSTEM. 

Hemorrhoids. — Haemorrhoids  and  varicose  veins  are  very  con- 
stant occurrences  during  pregnancy.  As  a  rule  they  are  slight  in 
degree,  and  pass  off  with  the  other  temporary  effects  of  preg- 
nancy. In  some  cases,  on  the  other  hand,  they  are  severe  in 
degree,  and  persist  permanently. 

Causes. — The  frequency  with  which  haemorrhoids  occur  during 
pregnancy  is  due  to  the  increased  resistance  to  venous  return 
through  the  pelvis,  caused  by  the  presence  of  the  enlarged  uterus, 
and  also  to  the  increased  quantity  of  blood  which  goes  to  the 
pelvis  during  pregnancy.  Varicosities  of  the  vulvar  and  vaginal 
veins  and  of  the  veins  of  the  leg  are  also  of  common  occurrence, 
and  are  due  to  the  former  cause.  As  a  rule,  the  varicosities  which 
occur  on  the  legs  are  capillary,  and  are  formed  by  a  network  of 
tiny  dilated  vessels.  The  veins  of  the  left  side  are  most  affected, 
in  consequence  of  the  relation  of  the  rectum  to  the  intra-pelvic 
veins. 

Symptoms. — -The  symptoms  caused  by  haemorrhoids  are  often 
most  distressing,  particularly  towards  the  end  of  pregnancy.  The 
common  capillary  varicosities  of  the  veins  of  the  leg  do  not  as  a 
rule  give  rise  to  any  inconvenience,  but  if  the  larger  veins  are 
involved  they  may  give  rise  to  so  much  pain  and  oedema  of  the 
leg  as  to  render  walking  or  standing  most  painful,  and  even  rupture 
of,  or  thrombosis  in,  a  vein  may  result. 

Treatment. — The  prophylactic  treatment  of  haemorrhoids  con- 
sists in  the  regulation  of  the  bowels  and  in  avoiding  all  long 
standing  or  excessive  exercise.  If  they  occur,  palliative  treat- 
ment is  all  that  can  be  adopted  or  is  necessary,  save  in  the  most 
exceptional  cases.  The  motions  must  be  kept  soft  and  regular, 
and  after  the  emptying  of  the  rectum  a  suppository  containing 


476  THE  PATHOLOGY  OF  PREGNANCY 

extract  of  witch  hazel  may  be  introduced  into  the  bowel,  or  a 
small  quantity  of  the  extract  itself,  diluted  with  an  equal  quantity 
of  water,  may  be  injected  with  a  small  rectal  syringe.  If  the 
haemorrhoids  are  prolapsed,  they  should  be  replaced  and  kept 
up  if  possible.  If  this  cannot  be  done,  or  if  the  haemorrhoids 
are  external,  bathing  with  water  containing  a  small  quantity  of 
laudanum  may  give  relief.  If  the  haemorrhoids  are  inflamed, 
a  hot  compress  or  the  old-fashioned  bread -poultice  is  most 
soothing.  In  addition,  the  parts  round  the  rectum  and  the 
haemorrhoids  themselves  should  be  bathed  several  times  during 
the  day  with  warm  water,  to  which  a  little  extract  of  witch 
hazel  has  been  added.  In  very  rare  cases,  if  the  pain  caused 
by  the  condition  is  so  great  as  to  interfere  with  the  patient's 
sleep  and  health,  or  if  continued  bleeding  is  occurring,  and 
relief  cannot  be  obtained  by  means  of  palliative  measures,  it 
may  be  necessary  to  adopt  radical  measures  and  to  ligature  or 
remove  the  haemorrhoids.  Such  cases  are,  however,  very  rare, 
as  in  almost  all  instances,  even  if  the  haemorrhoids  are  very 
severe,  radical  measures  can  be  postponed  until  after  delivery. 

Varicosities  of  the  vulvar  veins  do  not  as  a  rule  call  for  any 
special  treatment.  If  they  are  associated  with  cedema  of  the 
parts,  relief  may  be  afforded  by  wearing  a  soft  support  applied 
in  the  manner  of  a  diaper.  If  this  is  not  sufficient,  it  may  be 
necessary  for  the  patient  to  remain  in  bed  in  a  recumbent 
position. 

Varicosities  of  the  veins  of  the  leg,  if  confined  to  capillary 
vessels,  do  not  call  for  any  special  treatment  beyond  the  avoid- 
ance of  prolonged  standing  or  exercise  and  the  regulation  of  the 
bowels.  If  the  larger  veins  become  involved,  an  elastic  stocking 
or  bandage  may  be  worn.  Only  in  rare  cases,  where  rupture  is 
threatening,  is  a  radical  operation  indicated  during  pregnancy, 
as  even  the  severest  cases  will  be  temporarily  alleviated  by  rest 
in  bed. 

Anaemia. — Under  normal  cirumstances,  the  number  of  red 
blood  corpuscles  in  the  body  is  increased  during  pregnancy,  but 
sometimes,  owing  to  mal-nutrition,  unhealthy  surroundings,  in- 
sufficient food,  or  the  like,  the  opposite  condition  may  occur,  and 
the  patient  become  anaemic.  This  condition  exercises  a  prejudicial 
effect  upon  the  heart  and  the  other  general  functions  of  the  body, 
but  is  usually  amenable  to  treatment.  On  the  other  hand,  it  may 
sometimes  pass  into  a  condition  of  progressive  pernicious  anaemia, 
the  prognosis  of  which  is  extremely  bad. 

Treatment. — The  treatment  of  simple  anaemia  consists  in  the 
regulation  of  the  bowels,  the  removal  of  all  factors  which  tend  to 
cause  or  to  perpetuate  the  condition,  and  the  administration  of 
iron  and,  perhaps,  small'  doses  of  arsenic.  Plenty  of  good  and 
easily  digested  food,  fresh  air,  and  moderate  exercise  are  also 
necessary  adjuncts.      Iron   is  most   usually   administered  in  the 


HYDRSEMIA  477 

form  of  the  carbonate,  as  in  Blaud's  pill ;  it  may  also  be  given  in 
combination  with  aloes,  as  in  the  Pil.  Aloes  et  Ferri  of  the  Pharma- 
copoeia ;  or  as  Ferrum  Redactum,  a  form  which  was  particularly 
recommended  by  Lusk. 

Hydremia. — A  certain  degree  of  hydraemia,  or  increase  in  the 
amount  and  the  proportion  of  the  watery  elements  of  the  blood, 
is  the  rule  in  pregnancy.  If,  however,  the  physiological  degree 
is  .exceeded,  various  unpleasant  symptoms  may  follow.  Such  a 
condition  is  usually  associated  with  anaemia,  and  leads  to  oedema 
of  the  lower  extremities  and  of  the  vulva,  as  well  as  in  occasional 
cases  to  the  occurrence  of  serous  effusions  in  the  thoracic,  peri- 
toneal, and  pericardial  cavities.  Occasionally,  the  oedema  of  the 
vulva  may  reach  such  an  extent  that  the  labia  become  enormously 
swollen,  reaching  even  to  the  size  of  a  fcetal  head,  and  in  such 
cases  the  pressure  upon  the  skin  of  the  labium  may  be  so  great 
as  to  cause  its  rupture  or  sloughing,  or  even  gangrene  of  the  part 
may  result  from  interference  with  the  blood-supply. 

A  slight  degree  of  hydraemia  is  not  of  any  great  clinical  im- 
portance, save  in  that  it  may  be  confused  with  renal  disease  on 
account  of  the  accompanying  oedema.  A  diagnosis  can  be  made 
by  a  careful  qualitative  and  microscopical  examination  of  the 
urine.  Severe  degrees  of  hydraemia,  in  which  the  accompanying 
oedema  is  great,  are  of  importance  for  several  reasons.  In  the 
first  place,  the  health  of  the  patient  suffers  in  consequence  of  the 
inability  to  take  exercise  and  from  the  accompanying  anaemia. 
Further,  gangrene  or  rupture  of  a  swollen  labium  may  occur, 
leading,  perhaps,  to  the  establishment  of  a  centre  for  septic 
infection  closer  to  the  genital  tract  than  is  safe.  Finally,  the 
enlarged  labia  and  vulva  may  offer  an  obstruction  to  the  birth 
of  the  foetus,  while  the  bloodless  and  water-logged  condition  of 
the.  parts  renders  them  so  soft  that  extensive  lacerations  may 
occur.  Such  lacerations  will  probably  fail  to  unite,  even  if 
sutured. 

Treatment.  —  Proper  attention  to  the  hygiene  of  pregnancy  will 
usually,  but  not  always,  avert  the  occurrence  of  a  pathological 
degree  of  hydraemia.  Slight  oedema  requires  no  special  treat- 
ment, save  the  avoidance  of  too  long  standing  or  excessive 
exercise.  If  the  oedema  becomes  marked,  the  patient  must  rest 
in  the  recumbent  position,  the  legs  being  raised.  Distension  of 
the  labia  may  be  further  treated  by  the  application  of  lead  lotion. 
The  parts  should  not  be  punctured,  if  it  is  at  all  possible  to  avoid 
doing  so,  on  account  of  the  difficulty  of  keeping  the  wound  aseptic 
in  the  bloodless  condition  of  the  tissues.  If,  however,  gangrene 
threatens,  puncture  may  have  to  be  performed,  and  in  such  cases 
every  aseptic  precaution  must  be  taken.  The  administration  of 
iron  has  not  been  attended  by  any  great  benefit  in  these  cases, 
save  so  far  as  its  effect  upon  the  accompanying  anaemia  is  con- 
cerned.     Hydragogue   purgatives   are  contra-indicated,  as   they 


478  THE  PATHOLOGY  OF  PREGNANCY 

tend  to  still  further  impoverish  the  blood,  and  so  to  aggravate 
the  condition  (Lusk*).  Good  feeding  and  the  administration  of 
cod-liver  oil  and  malt  extract  will  be  most  likely  to  be  of  service. 

DISORDERS  OF  THE  NERVOUS  SYSTEM 

Neuralgia. — Neuralgic  pains,  occurring  particularly  over  the 
trigeminal  and  facial  branches  of  the  fifth  nerve,  are  often  met 
with  during  pregnancy.  They  do  not  possess  any  special  signifi- 
cance, and  pass  away  with  the  other  temporary  effects  of  pregnancy. 
Toothache  and  face-ache  are  the  most  common  forms  in  which 
they  occur,  and  mammary  and  intercostal  pains  may  also  occur  as 
the  result  of  the  irritation  of  other  nerves. 

Treatment. — If  any  definite  cause  for  the  pain  can  be  found, 
such  as  carious  teeth,  it  must  be  removed  or  alleviated.  There 
is  no  reason  why  the  extraction  of  a  tooth  or  the  stopping  of  a 
cavity  should  not  be  performed  during  pregnancy  ;  indeed,  such 
an  operation  is  very  much  preferable  to  the  constant  interference 
which  pain  will  cause  with  the  comfort  and  rest  of  the  patient. 
In  simple  neuralgia,  local  applications  of  warmth  or  of  camphor 
or  chloroform  liniment  will  sometimes  give  relief.  Small  doses  of 
tincture  of  gelsemium,  or  of  quinine,  phenacetine,  or  hyoscyamus 
may  be  given  internally.  If  the  pain  is  very  severe,  it  may  be 
necessary  to  resort  to  the  use  of  morphia,  or  a  kindred  drug  ;  but 
if  possible  its  use  should  be  avoided.  In  addition  to  the  ad- 
ministration of  drugs  for  alleviating  pain,  the  digestion  should  be 
carefully  attended  to  and  any  constipation  removed.  If  the 
patient  is  anaemic,  iron  and  arsenic  may  be  administered. 

Insomnia.- — Insomnia  is  not  a  common  occurrence  in  pregnancy, 
but  in  the  few  cases  in  which  it  occurs  it  has  a  most  prejudicial 
effect,  as  a  pregnant  woman  requires  the  full  amount  of  rest  to 
enable  her  to  make  up  for  the  increased  tissue  waste  which  goes  on, 
and  to  give  the  already  over-excited  higher  centres  a  period  of 
repose.  Nature  so  completely  recognises  this  necessity,  as  shown 
by  the  rarity  of  insomnia  in  pregnancy,  that  its  occurrence  must 
be  considered  as  of  serious  import,  and  as  pointing  perhaps  to  the 
onset,  or  actual  presence,  of  some  important  nervous  derange- 
ment. In  other  words,  the  occurrence  of  persistent  insomnia 
during  pregnancy  must  be  regarded  as  both  a  likely  causal  agent, 
and  as  a  symptom,  of  insanity. 

Treatment. — On  account  of  the  prejudicial  effect  of  insomnia 
upon  the  patient,  every  effort  must  be  made  to  induce  sleep  in 
those  cases  in  which  insomnia  occurs.  At  first,  an  attempt  should 
be  made  to  do  this  without  the  use  of  drugs.  Proper  exercise  in 
the  open  air,  a  warm  bath  before  retiring,  and  the  removal  of  all 
causes  which  may  tend  to  produce  mental  excitement,  will  some- 
times be  sufficient.  Hunger  is  a  common  cause  of  sleeplessness, 
*  '  Science  and  Art  of  Midwifery,'  fourth  edition,  p.  115. 


LONGINGS  OF  PREGNANCY  479 

even  though  it  is  not  sufficiently  marked  for  the  patient  to  be 
conscious  that  she  requires  food.  On  this  account,  a  glass  of 
milk  or  a  biscuit  before  going  to  bed  will  frequently  be  found 
to  help  sleep.  If  such  simple  measures  fail,  hypnotics  must 
be  administered,  as  their  use  is  a  less  evil  than  continued 
insomnia.  Sulphonal  or  trional  is  the  best  of  the  many  hypnotics 
at  our  disposal.  If  given  in  a  single  dose  of  from  ten  to  twenty 
grains  every  second  night,  they  will,  as  a  rule,  produce  sleep  with- 
out losing  their  effect ;  and,  as  in  many  cases  where  there  is  no 
pain,  a  sleepless  night  is  the  result  of  previous  sleepless  nights,  the 
obtaining  of  a  natural  sleep  by  means  of  a  hypnotic  for  a  week  or 
so  may  enable  the  patient  to  subsequently  sleep  without  its  aid. 
If  sulphonal  is  found  unsuitable  or  unsuccessful,  chloral,  bromide 
of  potassium,  or  bromidia  may  be  tried,  and,  if  they  fail,  nepenthe 
or  codeine.  Opium  or  morphia  should  only  be  used  as  a  last 
resource. 

Longings. — The  so-called  longings  of  pregnancy,  or  pica, 
are  rarely  met  with  at  the  present  day,  and  seem,  like  '  the 
vapours '  and  such  kindred  complaints,  to  have  in  great  part 
disappeared,  in  consequence  of  the  greater  number  of  interests 
of,  and  the  more  active  life  lead  by,  women.  Lusk*  considered 
that  they  were  in  great  measure  mythical,  but  when  we  note  the 
constant  references  to  them  by  the  older  writers,  both  lay  and 
medical,  it  can  scarcely  be  denied  that,  whether  they  occur  at 
the  present  day  or  not,  they  were  relatively  common  in  past 
times — indeed,  so  common  that  they  were,  and  still  are  by  many, 
regarded  as  a  subjective  symptom  of  pregnancy.  Longings 
principally  affect  the  appetite,  but  also  lead  to  strange  perversions 
of  the  ideas,  inclinations,  and  antipathies  of  the  patient.  Those 
who  desire  further  information  regarding  them  will  find  excellent 
descriptions  in  Montgomery' st  and  Parvin'sJ  works. 

Before  leaving  the  subject  of  the  disorders  of  pregnancy,  we 
should  like  to  echo  Lusk's  remarks  on  their  treatment.  It  is  vain 
to  endeavour  to  treat  all  the  disorders  of  pregnancy  seriatim,  as  by 
so  doing  we  inevitably  rivet  the  attention  of  the  woman  on  her 
condition  to  an  undue  extent,  and  only  lead  to  a  fancied  aggrava- 
tion of  her  discomforts.  When  these  disorders  are  slight,  the 
best  remedy  is  a  proper  degree  of  attention  to  the  hygiene  of 
pregnancy,  and  the  distraction  of  the  patient's  mind  from  their 
existence  by  a  proper  proportion  of  pleasures  and  occupations. 
When,  on  the  other  hand,  they  become  severe,  and,  by  interfering 
to  too  great  an  extent  with  the  comfort  of  the  patient,  commence 
to  react  injuriously  upon  her  health,  every  effort  must  be  made 
to  cope  with  and  remove  them. 

*   'The  Science  and  Art  of  Midwifery,'  fourth  edition,  p.  112. 
t  '  Signs  and  Symptoms  of  Pregnancy. ' 
t  '  The  Science  and  Art  of  Obstetrics.' 


CHAPTER  II 
DISEASES  OF  THE  DECTDILE  AND  OVUM 

Decidual  Endometritis,  Acute,  Chronic — Abnormal  Permeability  of  the  Mem- 
branes— Vesicular  Mole — Chorion-Epithelioma  or  Deciduoma  Malignum 
— Hydramnios— Oligo-hydramnios — Syphilis  of  the  Ovum — Anomalies 
and  Diseases  of  the  Placenta,  Anomalies  of  Position,  of  Size  and  Shape, 
Tumours,  QEdema,  Tuberculosis,  Calcareous  Degeneration,  Placental 
Infarction,  Placenta  of  Renal  Disease — Anomalies  of  the  Umbilical  Cord, 
of  Length,  of  Development,  Abnormal  Insertion. 

DECIDUAL    ENDOMETRITIS 

Decidual  Endometritis  is  a  most  important  condition,  and  is 
of  by  no  means  infrequent  occurrence  during  pregnancy. 

Varieties.  —  Two  varieties  of  decidual  endometritis  are  met 
with :  —  Acute  decidual  endometritis ;  and  chronic  decidual 
endometritis. 

Acute  Decidual  Endometritis. — This  rare  condition  is  the  local 
manifestation  of  different  acute  infectious  diseases.  In  consequence 
of  the  altered  blood-pressure,  of  the  presence  of  toxins  in  the  blood, 
or  more  rarely  owing  to  direct  infection  by  bacteria  in  the  blood, 
inflammatory  and  hemorrhagic  changes  occur  in  the  decidua.  In 
all  probability  those  diseases  which  are  associated  with  sudden 
and  considerable  alteration  of  temperature  are  most  prone  to 
cause  this  condition.  A  typical  case  occurring  as  a  result  of 
cholera  has  been  described  by  Slavjanski,*  in  which  the  decidua 
was  thickened,  dark  purple  in  colour,  and  full  of  extravasated 
blood.  Somewhat  similar  conditions  have  also  been  described  as 
occurring  in  measles  (Klotzf).  It  is  probable  that  in  all  cases  in 
which  the  condition  occurs,  abortion  results.  Microscopically, 
these  cases  are  marked  by  an  increase  in  the  number  and  size  of 
the  decidual  cells,  and  by  a  round-celled  infiltration.  The  latter 
is  sometimes  so  excessive  as  almost  to  entirely  hide  the  decidual 
cells  themselves,  and  in  such  cases  a  layer  of  pus  may  cover  the 
surface  of  the  decidua. 

*  Archiv  v.  Gyn.,  vol.  iv.,  p.  285. 
+  Ibid,,  vol.  xxix.,  p.  448. 


CHRONIC  DECIDUAL  ENDOMETRITIS  481 

Chronic  Decidual  Endometritis. — Chronic  decidual  endometritis 
is  a  condition  of  comparatively  frequent  occurrence,  and  is  one  of 
the  commonest  causes  of  abortion. 

Pathological  Anatomy. — As  in  cases  of  endometritis  in  the  non- 
pregnant, decidual  endometritis  may  result  in  hypertrophy  or 
atrophy  of  the  decidua.  The  former  change  is  the  more  common, 
a  fact  which  is  in  all  probability  due  to  the  effect  produced  by 
atrophy,  as  if  the  atrophy  affects  the  decidua  vera  and  reflexa 
only,  it  does  not  cause  any  symptoms,  and  hence  is  not  noticed, 
whereas  if  it  affects  the  decidua  serotina  it  in  all  probability 
produces  abortion  before  the  atrophic  changes  are  sufficiently 
marked  to  make  them  noticeable  in  the  expelled  ovum. 


*Zh, 


F  *    v^*4«    ,,   ? 


■&%?:-!?£> 


-s.rs^.-sk.a-»*.».s?-*,j«i. 

Fig.  259. — Decidual  Endometritis,      x  280. 
(Williams.) 

In  the  hypertrophic  form,  there  is  a  general  hyperplasia  of  all 
the  elements  of  the  decidua,  which  in  consistency  is  softer  than 
normal  and  contains  large  vascular  spaces.  In  some  cases,  the 
decidua  may  reach  a  thickness  of  half  an  inch  or  more,  and 
may  closely  invest  the  entire  ovum.  If  any  of  the  enlarged 
vascular  spaces  rupture,  haemorrhage  occurs  into  the  substance 
of  the  decidua  and  particularly  collects  between  the  decidua  and 
the  membranes  of  the  ovum.  The  blood  then  clots  and  layers 
of  fibrin  are  deposited  upon  the  chorionic  villi.  As  a  result 
of  this  condition,  the  membranes,  instead  of  presenting  a 
smooth  surface  towards  the  foetus,  present  a  surface  covered 
with  hills  and  hollows,  resembling  a  mass  of  thrombosed  veins 
(v.  Fig.  260).  If  a  section  is  made  through  the  decidua,  the  hills 
are  found  to  be  composed  of  masses  of  fibrin,  outside  which  lies  a 
greatly  thickened  decidua,  which  is  also  full  of  extravasated  blood. 

31 


4S2  THE  PATHOLOGY  OF  PREGNANCY 

To  this  condition  the  term  '  apoplectic  ovum '  has  been  applied. 
Such  an  alteration  in  the  character  of  the  decidua  necessarily 
interferes  with  the  blood  supply  of  the  embryo,  and  in  consequence 
the  latter  dies  usually  during  the  first  two  months  of  pregnancy. 
It  may  then  be  absorbed  and  disappear,  or  it  may  be  found  as  a 
tiny  almost  unrecognisable  mass  hanging  at  the  end  of  a  short 
and  often  bladder-like  cord.  Fothergill  describes  the  histological 
changes  which  occur  after  the  death  of  the  foetus  as  follows : — ■ 
'  After  the  death  of  the  ovum  and  the  stoppage  of  the  chorionic 
circulation  the  small  foetal  vessels  in  the  villi  disappear,  the  larger 
ones  being  more  slowly  obliterated,  leaving  for  some  time  a  few 
blood-crystals  and  amorphous  granules  to  mark  their  late  position. 


Fig.  260. — An  '  Apoplectic  Ovum.' 
F,  Foetus  ;  B,  sub-amniotic  fibrinous  masses  ;  C,  chorion  ;  D,  decidua. 

The  foetal  connective  tissue  between  the  epithelial  layers  of  the 
amnion  and  the  chorion,  as  also  that  forming  the  cores  of  the 
villi,  is  compressed,  but  is  not  otherwise  altered  for  a  long  time. 
The  foetal  epithelium  lining  the  amniotic  cavity  also  remains 
recognisable,  but  the  outlines  of  its  cells  are  lost  and  the  nuclei 
become  clouded.  The  foetal  epithelium  of  the  chorion  and  the 
chorionic  villi  undergo  similar  changes.  When  this  epithelial 
covering  of  the  villi  degenerates  after  the  stoppage  of  the  foetal 
circulation,  the  maternal  blood  in  the  intervillous  spaces  does 
not  long  continue  to  move,  but  soon  forms  a  firm  blood-clot 
embedding  the  villi.'  If  the  amount  of  intra-decidual  haemor- 
rhage is  sufficient  to  effect  the  detachment  of  the  decidua  and 
ovum  from  the  uterus,  abortion  occurs.  If,  however,  a  slight 
vascular  connection  with  the  uterus  still  persists,  the.  decidual 
cells  may    continue    to    multiply,    the   masses  of  fibrin   become 


CHRONIC  DECIDUAL  ENDOMETRITIS  483 

organised,  the  remains  of  the  chorionic  villi  disappear,  and  the 
ovum  becomes  converted  into  a  mass  of  tissue  resembling  the 
decidua.  To  this  condition,  the  terms  placental  or  fibrinous 
polypus,  or  deciduoma  benignum  have  been  applied. 

Occasionally,  small  polypoid  or  club-like  excrescences  appear 
over  the  surface  of  the  decidua,  and  bulge  into  the  uterine  cavity, 
and  between  these  elevations,  the  mouths  of  the  uterine  glands 
can  be  detected.  To  this  condition  the  term  endometritis  decidua 
polyposa  vel  tubevosa  was  applied  by  Virchow.*  Another  rare  form 
of  decidual  endometritis  is  that  known  as  endometritis  decidua  cystica, 
in  which  the  decidua  is  studded  over  by  small  projections  com- 
posed of  retention  cysts  due  to  blocking  of  the  mouth  of  the 
uterine  glands  (v.  Fig.  261). 

When  the  decidual  endometritis  gives  rise  to  a  profuse  watery 


Fig.  261. — Endometritis  Decidua  Cystica. 
(Breus. ) 

discharge,  the  term  catarrhal  decidual  endometritis,  or  shortly 
catarrhal  endometritis,  is  applied  to  it,  while  to  the  watery 
discharge  which  it  causes  the  term  decidual  hydrorrhcea  is 
applied.  Hydrorrhcea  gravidarum  is  the  term  applied  to  any 
watery  discharge  which  occurs  during  pregnancy,  and  from  long 
custom  has  come  to  be  considered  to  be  a  definite  pathological 
condition.  This  is,  however,  not  a  correct  manner  of  regarding 
it,  as  it  is  no  more  a  definite  condition  than  is  leucorrhcea.  It  is 
a  symptom  of  various  pathological  conditions,  and  as  its  aetiology 
is  now  sufficiently  established,  it  is  quite  time  to  refer  to  it  as  a 
symptom,  and  not  to  consider  it  separately  as  if  it  was  a  distinct 
disease.  In  decidual  hydrorrhcea,  the  decidua  is  inflamed,  the 
glands  being  particularly  involved,  and  a  watery  fluid  is  secreted 
by  them  which  accumulates  in  pouches  between  the  decidua 
vera  and  the  reflexa.  When  the  amount  of  fluid  in  a  pouch  has 
become   so  considerable  that   there  is  no  further    room    for   its 

*  Monats.   b.   Gebuytskunde,   xix. ,  p.   242  ;  and  Die   krankhaften  Geschwuhte, 
1864,  ii.,  pp.  478-481. 

3T— 2 


484  THE  PATHOLOGY  OF  PREGNANCY 

storage,  it  bursts  its  way  downwards  and  escapes  through  the 
uterine  orifice.  The  pathological  changes  in  this  condition  were 
carefully  noted  in  a  case  recorded  by  Duclos,  which  occurred  in 
a  patient  who  committed  suicide  prior  to  the  expulsion  of  the 
ovum.  The  patient  was  pregnant  for  about  six  and  a  half 
months,  and  had  had  an  attack  of  hydrorrhcea  three  weeks 
previously.  Between  the  inner  aspect  of  the  uterus  and  the 
membranes,  there  were  two  pouches  situated  on  the  lateral  wall 
and  at  some  little  distance  from  one  another.  These  were  filled 
with  a  clear  fluid  of  a  yellow  tinge,  and  this  fluid,  as  well  as 
that  which  had  previously  been  expelled,  was  evidently  derived 
from  the  uterine  glands.  In  another  place,  there  was  an  empty 
pouch,  which  was  apparently  that  from  which,  the  hydror- 
rhcea had  come  in  the  first  instance.  Fig.  261  shows  a  case  of 
so-called  endometritis  decidua  cystica,  in  which  a  collection  of 
small  cysts  project  from  the  surface  of  the  decidua  in  consequence 
of  the  blockage  of  the  ducts  of  secreting  glands.  Such  a  condition 
is  probably  the  preliminary  stage  in  the  formation  of  pouches. 

Aetiology. — The  cause  of  chronic  decidual  endometritis  is  in 
most  cases  a  pre-existing  endometritis,  that  is  to  say,  a  fertilised 
ovum  becomes  implanted  upon  a  diseased  endometrium,  which 
in  turn  forms  a  diseased  decidua.  In  all  probability,  decidual 
endometritis  may  also  result  from  an  undue  congestion  of  the 
uterus  during  pregnancy,  even  when  the  endometrium  was 
previously  healthy.  Backward  displacements  of  the  uterus 
are  particularly  prone  to  give  rise  to  such  congestion,  and 
as  is  well  known,  they  are  frequently  the  prime  cause  of 
abortion.  During  the  process  of  replacing  a  retro-deviated 
uterus,  we  can  frequently  notice  the  flaccid  and  soft  condition  of 
the  uterus  before  reposition  and  the  sudden  increase  in  firmness 
which  occurs  when  the  uterus  is  replaced.  This  change,  in  the 
case  of  a  pregnant  uterus,  is  undoubtedly  in  part  due  to  a 
temporary  contraction  of  the  fibres  brought  about  by  the 
stimulus  of  reposition,  but  also  it  is  in  great  part  permanent,  and 
shows  that  prior  to  reposition  the  uterus  was  in  an  unduly  soft 
condition,  and  so  was  receiving  a  greater  blood  supply,  and  holding 
more  blood  in  its  vessels,  than  it  would  have  done  if  the  muscle 
fibre  possessed  a  normal  tone. 

Syphilis  and  renal  diseases  are  also  in  all  probability  common 
causes  of  decidual  endometritis,  and  particularly  affect  the  decidua 
serotina.  On  this  account,  the  changes  which  they  produce  will 
be  referred  to  later  when  discussing  placental  lesions. 

Symptoms. — Decidual  endometritis  may  cause  slight  recurrent 
haemorrhages,  the  death  and  expulsion  of  the  ovum,  or  hydrorrhcea. 
In  the  last  case,  the  accumulation  of  fluid  may  commence  at  any 
time  after  the  decidua  vera  and  decidua  reflexa  have  come  into 
contact  with  one  another,  and  the  first  escape  of  fluid  may  thus 
occur  from  the  fourth  month  onwards.  At  first,  half  an  ounce 
or  so  is  all  that  escapes,  but  as  the  uterus  enlarges,  and  as,  con- 


CHRONIC  DECIDUAL  ENDOMETRITIS  485 

sequently,  there  is  room  for  a  greater  accumulation  of  fluid,  the 
amount  which  comes  away  at  one  time  may  amount  to  fourteen 
ounces  or  even  a  pint.  If  the  discharge  is  large  in  quantity  and 
escapes  frequently,  the  condition  of  the  patient  may  be  affected 
prejudicially  by  it,  but  ordinarily  it  produces  little  or  no  con- 
stitutional effect. 

Diagnosis. — Decidual  endometritis  can  only  be  recognised 
during  the  continuance  of  pregnancy  in  the  cases  in  which  it  gives 
rise  to  hydrorrhcea.  In  other  cases,  its  existence  is  only 
determined  when  it  has  caused  abortion,  although  its  presence 
may  be  suspected  owing  to  the  occurrence  of  repeated  slight 
attacks  of  haemorrhage.  The  only  point  in  the  diagnosis  which 
is  of  clinical  importance  is  the  recognition  of  the  origin  of  the 
watery  discharge.  This  may  be  due  to  decidual  endometritis,  or 
to  one  of  three  other  conditions  : — 

(1)  Involuntary  Escape  of  Urine. — This  can  be  distinguished 
from  decidual  hydrorrhcea  by  examining  the  patient  as  soon  after 
the  flow  has  come  away  as  possible.  If  the  flow  has  come  from 
the  uterus,  the  vagina  will  be  moist.  Further,  if  any  of  the 
escaped  fluid  can  be  obtained,  it  will  be  found  to  be  neutral  or 
alkaline  in  the  case  of  hydrorrhcea,  and  usually  acid  in  the  case  of 
urine. 

(2)  Rupture  of  the  Membranes. — This  naturally  only  occurs 
once  and  is  followed  by  the  onset  of  labour.  Moreover,  on  palpa- 
tion, the  uterine  walls  will  be  found  contracted  down  upon  the 
fcetus. 

(3)  So-called  'Amniotic  Hydrorrhcea.'  —  This  is  the  term 
applied  to  the  escape  of  liquor  amnii  through  minute  tears 
in  the  membranes,  or  by  transudation  through  the  mem- 
branes. It  is  difficult  or  impossible  to  distinguish  between 
it  and  decidual  hydrorrhcea,  though,  according  to  Pinard,  it 
is  possible  to  do  so  by  the  examination  of  the  fluid,  as  in  the 
case  of  amniotic  hydrorrhcea  the  fluid  contains  hairs,  debris,  and 
vernix  caseosa.  If,  however,  the  fluid  has  transuded  through 
the  membranes  or  passed  through  minute  cracks,  it  will  be 
so  filtered  that  all  such  matter  will  have  been  excluded.  The 
onset  of  premature  labour  is  more  likely  to  follow  in  the  case  of 
amniotic  hydrorrhcea  than  in  the  case  of  decidual  hydrorrhcea, 
but  this  fact  does  not  help  us  in  making  a  diagnosis  at  the  time 
that  it  is  important  to  do  so — i.e.,  at  the  time  of  the  occurrence 
of  the  flow. 

Treatment. — The  treatment  of  decidual  endometritis  is  in  the 
main  prophylactic,  inasmuch  as  once  it  occurs  little  can  be  done 
while  pregnancy  continues.  If  a  patient  suffers  from  chronic 
endometritis,  it  must  be  treated  and  cured  by  curetting  and  other 
means  when  she  is  not  pregnant.  During  pregnancy,  all  that  can 
be  done  is  to  remove  any  cause  of  congestion  which  may  be 
present,  such  as  uterine  displacements,  and  possibly  to  promote  a 
more  healthy  tone  in  the  uterine  fibre,  and  so  to  regulate  the 


486  THE  PATHOLOGY  OF  PREGNANCY 

amount  of  blood  going  to  the  uterus,  by  the  administration  of 
ergot  and  strychnine.  There  is  considerable  difference  of  opinion 
as  to  the  advisability  and  utility  of  administering  ergot  during 
pregnancy  in  cases  in  which  the  patient  suffers  from  slight 
recurrent  haemorrhages.  Many  obstetricians  are  opposed  to  its  use 
on  the  ground  that  any  effect  it  may  have  on  haemorrhage  it 
produces  by  inducing  uterine  contractions,  and  that  such  contrac- 
tions will  increase  the  tendency  to  premature  expulsion  of  the 
ovum.  Atthill,*  on  the  other  hand,  considered  that  the  ad- 
ministration of  ergot  and  strychnine  in  combination  exerts  a 
valuable  tonic  effect  upon  the  uterine  muscle,  and  strongly 
recommends  its  use  in  cases  of  slight  haemorrhage  in  the  early 
months.  He  administered  five  minim  doses  of  Liquor  Strychninae 
and  fifteen-minim  doses  of  Liquid  Extract  of  Ergot,  three  times  a 
day,  continued  for  several  weeks.  We  have  adopted  his  sugges- 
tion in  several  cases,  with  the  object  of  checking  recurrent 
haemorrhages,  with  the  result  that  the  haemorrhage  ceased  and 
pregnancy  continued  to  full  term.  Whether  such  results  are  to 
be  attributed  to  the  administration  of  ergot  or  not,  there  is  no 
doubt  that  the  drug  may  be  safely  given  in  the  doses  mentioned, 
and  that  it  apparently  exerts  a  beneficial  influence.  Accordingly, 
we  recommend  that  Atthill's  prescription  be  tried  in  these  cases. 
The  administration  of  Hydrastis  Canadensis  has  also  been  recom- 
mended on  account  of  its  action  in  causing  contraction  of  the 
fibres  of  the  blood-vessels  without  producing  any  effect  upon  the 
uterine  muscle.  The  usual  dose  of  the  drug  is  from  fifteen  to 
twenty  minims  of  the  Liquid  Extract,  but  we  cannot  say  that  we 
have  ever  noticed  any  good  effects  which  were  even  remotely 
attributable  to  its  use. 

If  decidual  hydrorrhoea  occurs,  the  patient  must  be  kept  in  bed 
for  a  few  days  after  each  escape  of  fluid,  on  account  of  the  risk 
that  the  sudden  flow  may  lead  to  the  occurrence  of  uterine  con- 
tractions. It  may  be  that  the  administration  of  ergot  and 
strychnine  may  be  of  benefit  in  these  cases  by  diminishing  uterine 
congestion.  Ergot,  however,  should  in  no  case  be  given  if  there 
is  any  indication  that  contractions  of  the  uterus  are  occurring. 
In  such  cases  opiates  may  be  given  instead. 

Prognosis. — -It  is  obviously  impossible  to  say  what  degree  of 
decidual  endometritis  is  compatible  with  the  continuance  of 
pregnancy,  and,  in  view  of  the  fact  that  we  can  so  rarely  do  more 
than  suspect  the  existence  of  the  condition  until  the  expulsion  of 
the  ovum  has  taken  place,  this  is  of  no  great  practical  importance 
so  far  as  treatment  is  concerned.  It  is,  however,  frequently 
necessary  to  give  a  prognosis  as  to  the  probable  interruption  or 
continuance  of  pregnancy  in  cases  of  hydrorrhoea.  In  all  such 
cases,  the  prognosis  must  be  most  guarded,  as  the  difficulty  of 
distinguishing  between  decidual  and  amniotic  hydrorrhoea  is  so 

*  '  On  the  Prevention  of  Post-partum  Haemorrhage,'  Trans.  Roy.  Acad.  Med. 
in  Ireland,  vol.  xv.,  p.  344. 


ABNORMAL  PERMEABILITY  OF  THE  MEMBRANES  487 

considerable.  If  we  are  positive  that  the  case  is  one  of  decidual 
hydrorrhcea,  our  prognosis  may  be  more  favourable,  and  is  based 
on  the  amount  of  fluid  which  has  escaped,  and  on  the  number  and 
amount  of  previous  attacks  if  any  have  occurred.  The  prognosis 
after  a  single  escape  of  fluid  is  good,  and  this  is  also  the  case 
when  the  amount  in  succeeding  flows  progressively  diminishes. 
If,  on  the  contrary,  the  amount  increases  each  time  fluid  escapes, 
the  probability  of  the  continuance  of  labour  is  not  considerable, 
while,  if  painful  contractions  of  the  uterus  once  commence,  it  is 
most  improbable  that  they  will  pass  off  and  that  pregnancy  will 
continue. 


ABNORMAL  PERMEABILITY  OF  THE  MEMBRANES 

In  certain  cases,  the  liquor  amnii  finds  its  way  in  small 
quantities  through  the  membranes  and  escapes  through  the 
uterine  orifice,  even  though  there  has  been  no  apparent  rupture 
of  the  membranes  ;  to  this  escape  of  fluid  the  term  amniotic 
hydrorrhcea  is  applied.  This  condition  is  a  more  common  cause 
ot  hydrorrhcea  than  is  decidual  endometritis  ;  it,  however,  occurs 
later  in  pregnancy,  and  is  rarely  met  with  before  the  eighth 
month. 

Aitiology. — The  pathology  of  this  condition  is  obscure.  In 
some  cases,  the  fluid  apparently  makes  its  way  through  small 
tears  in  the  membranes,  which  may  perhaps  be  the  result  of  some 
degenerative  process.  In  others,  the  amnion  is  in  great  part 
Avanting  and  transudation  of  fluid  occurs  through  the  chorion. 
In  others,  the  fluid  finds  its  way  through  the  amnion  alone,  and 
collects  in  a  pouch  between  the  membranes,  whence  it  escapes 
owing  to  rupture  of  the  chorion.  In  some  cases,  where  the 
hydrorrhcea  is  apparently  the  result  of  abnormal  permeability  of 
the  membranes,  the  latter  may  have  really  ruptured  high  up, 
while  the  uterine  orifice  is  still  undilated. 

Symptoms. — The  symptoms  of  this  condition  are  identical  with 
those  of  catarrhal  decidual  hydrorrhcea,  save  that  if  the  hydror- 
rhcea is  due  to  rupture  of  the  membranes,  it  may  come  away 
continuously  in  little  gushes.  If  the  hydrorrhcea  is  due  to  the 
rupture  of  a  pouch  between  the  membranes  and  the  uterine  wall, 
or  between  the  chorion  and  amnion,  the  fluid  comes  away  with  a 
rush,  as  in  decidual  hydrorrhcea. 

Treatment. — There  is  no  treatment  for  this  condition  save  to  do 
everything  to  prevent  the  onset  of  labour.  The  patient  must  be 
kept  at  rest  in  bed  for  several  days,  and  opiates  may  be  given 
with  the  object  of  checking  uterine  contractions. 

Prognosis. — The  probability  of  the  onset  of  labour  is  very  much 
greater  than  it  is  in  decidual  hydrorrhcea,  and  consequently  the 
prognosis  must  be  guarded  so  far  as  the  probable  onset  of  labour 
is  concerned. 


488  THE  PATHOLOGY  OF  PREGNANCY 


VESICULAR  MOLE 

Vesicular  mole,  myxoma  chorii,  or  hydatidiform  mole,  is  the 
term  applied  to  a  cystic  degeneration  of  the  chorionic  villi,  the 
result  of  the  proliferation  and  increased  activity  of  their  epithelial 
coverings.  The  change  usually  leads  to  the  death  of  the  foetus 
and  the  premature  expulsion  of  the  ovum.  The  term  '  myxoma 
chorii '  (Virchow)  originated  in  the  belief  that  the  mole  was  the 
result  of  a  myxomatous  degeneration  of  the  villi — a  belief  that  is 
now  known  to  be  incorrect,  though,  no  doubt,  the  degenerated 
villi  sometimes  contain  an  undue  amount  of  mucin. 

Frequency. — Vesicular  mole  is  a  rare  complication.  According 
to  Engel,  it  occurred  five  times  in  4,000  pregnancies,  a  pro- 
portion of  1  in  800.  This,  is  however,  probably  too  high  a 
proportion,  as  Madame  Boivin  only  met  with  it  once  in  20,000 
pregnancies.  At  the  Rotunda  Hospital,  12  cases  occurred 
amongst  20,000  pregnancies,  a  proportion  of  1  in  1666-6. 

JEtiology.  —  It  is  now  so  definitely  recognised  that  vesicular 
mole  is  the  result  of  a  pathological  condition  of  the  chorionic 
villi,  that  it  is  curious  to  recall  that,  at  one  time,  and  that  not  so 
long  ago,  the  condition  was  considered  by  many  to  be  sometimes 
in  no  way  associated  with  pregnancy.  So  recently  as  1887,  a 
distinguished  writer  on  obstetrical  subjects,  the  late  More 
Madden,  vigorously  contradicted  the  statement  of  Priestley*  that 
'  with  our  present  knowledge  it  would  be  as  reasonable  to  expect 
that  a  child  might  be  expelled  from  an  unimpregnated  uterus  as  a 
true  vesicular  chorion.'  More  Madden  considered  'that  cases 
may  also  occur  in  which  similar-looking  products  are  found  in  the 
uterus,  independently  of  impregnation.'}  The  various  ways  in 
which  the  occurrence  of  a  vesicular  mole  was  accounted  for 
are  so  numerous  and  unimportant  that  we  do  not  consider  it 
necessary  to  enumerate  them.] 

The  cause  of  the  alteration  in  the  villi  has  not  been  satisfac- 
torily explained.  Vesicular  mole  occurs  more  frequently  in 
middle-aged  than  in  young  women,  and  in  multipara?  than  in 
primiparae.     Out  of  thirty-five  collected  cases,  fourteen  women 

*  '  The  Pathology  of  Intra-uterine  Death,'  p.  112. 

+  Trans.  Roy.  Acad.  Med.  in.  Irel.,  vol.  vi. ,  p.  304. 

J  The  following  extract  from  Pare's  '  Surgery '  is  worthy  of  being  repro- 
duced, as  showing  some  of  the  peculiar  ideas  of  the  time  : — 'The  Countess 
Margaret,  daughter  of  Florent  IV.,  Earl  of  Holland,  and  spouse  to  Count 
Herman  of  Heneberg,  on  Good  Friday,  in  the  year  of  our  Lord  1276,  and  of 
her  age  forty-two,  brought  forth  at  one  birth  365  infants,  whereof  182  are  said 
to  have  been  males,  as  many  females,  and  the  odd  one  an  hermaphrodite,  who 
were  all  baptised,  those  by  the  name  of  John,  these  by  the  name  of  Elizabeth, 
in  two  brazen  vessels  by  Don  William,  Suffragan  Bishop  of  Treves.'  The 
occurrence  is  further  testified  to  by  a  tablet  in  the  church  of  Lonsdunen,  near 
Leyden,  where  the  Countess  and  her  '  children  '  lie  buried.  It  is  most  probable 
that  the  cysts  of  a  mole  were  considered  to  be  so  many  ova,  and  then  converted 
into  children  by  the  easy  credulity  of  the  times. 


THE  JETIOLOGY  OF   VESICULAR  MOLE  489 

were  between  twenty -five  and  thirty -five,  while  twenty -one 
were  above  thirty-five  (Hirtzmann).  There  is  also  an  apparent 
tendency  to  the  recurrence  of  molar  pregnancies  in  the  same 
woman.  In  three  recorded  cases,  one  patient  had  eleven  moles 
out  of  twelve  pregnancies  (Maier),  another,  three  moles  con- 
secutively (Depaul),  and  a  third  two  moles  consecutively  (War- 
mann).      Virchow*   considered    that    chronic    endometritis    had 


Fig.  262. — Diagram  showing  the  Formation  of  a  Vesicular  Mole. 

(Bumra.) 

some  causal  effect  on  the  production  of  moles,  and  Winckel 
agrees  with  this  opinion.  It  would,  however,  seem  to  be  more 
probable  that  the  condition  is  dependent  on  some  abnormal 
development  of  the  villi  themselves,  in  view  of  the  fact  that 
in  cases  of  twins  one  ovum  may  be  affected  while  the  other 
remains  healthy.  Spiegelbergf  regards  it  as  probable  that 
the  cause  is  to  be  sought  in  '  an  anomalous  development  of 
the   allantois.'      A  syphilitic    history  can    be  obtained    in    some 

*  Die  kvankhaften  Geschwulste,  1863,  i.,  pp.  405-414. 
f  Op.  tit.,  vol.  i.,  p.  456 


490  THE  PATHOLOGY  OF  PREGNANCY 

cases,  but  is  not  by  any  means  constant.  A  German  writer 
— Aichel:;: — reported  to  the  1901  German  Gynaecological  Congress 
that  he  had  been  able  to  produce  a  vesicular  mole  in  dogs  by 
destroying  the  vessels  going  to  the  decidua,  and  so  interfering 
with  the  nutrition  of  the  chorionic  villi.  Further  evidence  on 
this  point  is,  however,  still  required. 

Pathological  Anatomy.  —  The  macroscopical  appearance  of  a 
vesicular  mole  varies  somewhat  according  to  the  extent  to  which 
it  has  involved  the  ovum.  If  the  degeneration  is  advanced, 
the  entire  ovum  is  involved,  and  all  that  remains  of  the  original 
structure  of  the  latter  is  destroyed,  save  that  perhaps  a  small 
pouch  containing  fluid  may  persist  as  the  representative  of  the 
amniotic  sac.  If  the  degeneration  is  a  stage  less  advanced,  an 
amniotic  cavity  of  the  usual  size  may  be  found  invested  more  or 
less  completely  by  the  degenerated  chorion,  and  containing  no 
trace  of  embryo,  save  perhaps  a  little  detritus  or  a  fragment  of  the 
umbilical  cord.  In  these  cases,  the  foetus  has  been  absorbed.  To 
this  stage,  the  term  '  hollow  mole  '  has  been  sometimes  applied. 
If  the  degeneration  is  only  commencing,  or  has  proceeded  but 
a  short  way,  only  a  portion  of  the  chorionic  villi  is  affected,  and 
the  amniotic  sac  contains  a  foetus.  If  only  an  inconsiderable 
portion  of  the  chorion  is  thus  affected,  the  foetus  may  be  alive, 
but,  if  a  large  portion  is  involved,  the  foetus  will  be  dead. 

The  appearance  of  the  mole  itself  is  very  characteristic.  It  is 
composed  of  a  mass  of  small  cysts,  which  are  formed  along  the 
course  of  numerous  pedicles.  The  pedicle  corresponds  to  the 
original  chorionic  villus,  while  the  cyst  is  the  result  of  the 
accumulation  of  fluid  at  different  intervals  along  its  course. 
This  fluid  is  said  to  contain  salts,  albumen,  and  mucin,  and  is 
probably  due  in  great  part  to  oedema  of  the  stroma.  When  the 
mole  comes  away,  there  is  always  a  certain  amount  -of  haemor- 
rhage, and  this,  mingled  with  the  fluid  which  escapes  from 
ruptured  cysts,  produces  a  watery  blood-stained  fluid.  The 
cysts  floating  in  this  produce  an  appearance  which  is  well 
described  by  the  classical  simile  of  a  mass  of  white  currants 
floating  in  red  currant  juice.  The  cysts  vary  in  size  from  the 
size  of  pins'-heads  to  that  of  grapes. 

The  histological  character  of  vesicular  moles  has  been  care- 
fully studied  of  late  by  Fraenkel,t  Marchand,!  and  Franque.§ 
As  will  be  remembered,  the  core  of  the  normal  villus  is  com- 
posed during  the  early  months  of  a  stroma  of  mesoblastic  tissue 
resembling  the  Whartonian  jelly,  and  composed  of  stellate-shaped 
myxomatous  cells  lying  in  a  structureless  intercellular  substance. 
In  the  centre  of  this  core,  are  found  the  foetal  capillaries.  As 
pregnancy  advances  the  stroma  gradually  loses  its  myxomatous 

*  '  Ueber  die  Blasenmole,'  etc.,  Habilitationsschrift,  Erlangen,  1901. 
t  Arch.  f.  Gyn.,  1895,  vol.  xlix.,  481-507. 

1  Zeits.  /.  Geb.  und  Gyn.,  vol.  xxxii.,  1895,  405-472  ;  and  xxxix..  173-258. 
§  Ibid.,  vol.  xxxiv.,  1896 


THE  PATHOLOGICAL  ANATOMY  OF  VESICULAR  MOLE       491 

type,  and  comes  more  and  more  to  resemble  ordinary  connective 
tissue.     This  core  is  in  turn  covered  by  two  layers  of  cells  : — 

(1)  An  inner  layer  termed  Langhans'  layer,  which  invests 
the  stroma,  and  consists  of  cubical  or  flattened  cells  containing 
a  single  round  or  oval  nucleus.  This  layer  almost  completely 
disappears  after  the  end  of  the  fifth  month. 

(2)  An  outer  layer  known  as  the  syncytium,  and  composed  of 
large  multinuclear  cells  or  protoplasmic  masses.  Both  this  layer 
and  Langhans'  layer  are  derived  from  foetal  epiblast.     The  well- 

_______  s  s 

— r~       <•! i  *>  *-*j  ~  r. -•  uy 

■-.  »  .i   v*  ?   •■••i  .•■<:«,  V -S?-*  ■.  *•? 


;  :-? 


Fig.  263.— Section  of   Hydatidiform  Mole,  showing  Proliferation   of 

Syncytium  and  Langhans'  Cells,      x  75. 

S,  Syncytium  ;  V,  normal  chorionic  villi ;  Z,  Langhans' cells.     (Williams.) 

defined  cell  of  Langhans'  layer  is  probably  the  primitive  type  of 
cell,  and  the  differences  found  in  the  syncytium  are  probably 
due  to  the  effect  of  contact  with  the  maternal  blood.* 

In  the  vesicle  of  a  mole  these  three  layers  persist,  but  are 
somewhat  altered.  The  stroma  is  increased  in  amount,  and 
degenerated,  the  foetal  vessels  have  disappeared,   and  scattered 

*  Teacher,  '  Chorion-epithelioma,'  Trans.  Obstet.  Soc.  Lond.,  vol.  xlv.,  p.  261. 


492 


THE  PATHOLOGY  OF  PREGNANCY 


here  and  there  are  cells  which  are  probably  offshoots  of  Langhans' 
layer  and  protoplasmic  masses  from  the  syncytium.  The  cells  of 
Langhans'  layer  proliferate,  and  form  a  continuous  layer  round 
the  periphery  of  the  vesicle.  They  are  in  turn  covered  by  the 
syncytium,  which  in  places  shows  signs  of  proliferation.  The 
mole  is  thus  primarily  due  to  the  proliferation  and  increased 
activity  of  the  cells  of  Langhans'  layer  and  of  the  syncytium 
(v.  Fig.  263). 

If  the  mole  does  not  reach  any  great  size,  it  may  be  expelled 


Fig.  264. — Uterus  containing  a  Vesicular  Mole. 
(From  a  specimen  in  the  School  of  Physic,  Trinity  College,  Dublin.) 


while  still  invested  by  the  decidua,  into  which  the  cysts  lying 
most  externally  penetrate.  When  the  mole  has  reached  a  greater 
size,  the  decidua  may  have  thinned  and  in  part  disappeared,  and 
consequently  may  remain  behind  after  the  expulsion  of  the  mole 
and  be  subsequently  expelled  in  small  fragments.  In  rare  cases, 
the  mole  may  grow  through  the  decidua  and  so  gain  access  to  the 
uterine  wall.  If  it  in  turn  penetrates  into  the  latter,  the  clinical 
importance  of  the  case  is  altogether  altered,  and  we  have  to  do 
with  what  to  all  intents  and  purposes  is  a  malignant  growth.     A 


THE  SYMPTOMS  OF  VESICULAR  MOLE  493 

mole  which  has  grown  through  its  decidual  investment,  and 
penetrated  the  uterine  wall,  may  then  in  turn  grow  through  the 
latter  and  extend  outwards  into  the  peritoneal  cavity.  The  rela- 
tions between  this  condition  and  the  condition  commonly  known 
as  deciduoma  malignum  are  apparent,  though  it  is  by  no  means 
easy  to  explain  their  exact  nature.  They  will  be  more  satis- 
factorily discussed  under  the  head  of  the  latter  condition. 

Symptoms. — The  first  symptoms  of  myxomatous  degeneration  of 
the  chorion,  as  a  rule,  appear  during  the  second  or  third  month, 
and  consist  in  the  occurrence  of  a  watery  blood-stained  discharge 
and  crampy  pains  in  the  abdomen.  The  origin  of  the  former  has 
been  already  explained,  the  latter  are  due  to  spasmodic  efforts  of 
the  uterus  to  expel  the  mole.  As  the  pregnancy  continues,  these 
symptoms  persist  and  increase  in  severity,  while  at  the  same  time 
the  uterus  alters  in  size  according  as  the  mole  develops.  Usually, 
the  uterus  in  these  cases  is  considerably  larger  than  the  period  of 
pregnancy,  and  occasionally  this  increase  in  size  is  rapid. 
Tuefferd*  records  a  case  in  which  the  uterus  rose  in  fifteen  days 
from  the  level  of  the  symphysis  to  the  level  of  the  umbilicus— an 
increase  in  size  which,  under  normal  circumstances,  would  require 
two  months  to  occur.  Occasionally,  the  uterus  is  smaller  than  it 
ought  to  be  in  correspondence  with  the  period  of  pregnancy. 
This  occurs  when  the  mole  has  for  some  reason  ceased  to  grow, 
or  when  a  considerable  portion  of  it  has  been  already  expelled. 

On  palpation,  the  uterus  is  found  in  some  cases  to  be  more 
tense  than  usual,  in  others  to  be  more  boggy  and  soft.  Con- 
sequently, so  far  as  its  consistency  is  concerned,  we  can  only  say 
that  a  skilled  examiner  will  probably  be  able  to  detect  some  varia- 
tion from  the  normal.  The  fcetal  parts  cannot  be  felt  nor  ballotte- 
ment  obtained,  save  in  cases  of  twin  pregnancy,  where  only  one 
ovum  is  affected.  It  is  said  that  the  cervix  preserves  its  normal 
non-impregnated  shape  and  consistency  for  a  longer  time  in  the 
case  of  a  molar  pregnancy  than  in  the  case  of  a  normal  pregnancy 
(Legueu),  but  obviously  this  is  entirely  dependent  on  the  period 
at  which  the  degeneration  commences.  The  fcetal  heart  cannot 
be  heard  save  in  twin  cases  as  mentioned,  and  even  then  it  will 
probably  be  so  masked  by  the  affected  ovum  that  it  will  be 
impossible  to  detect  it. 

If  the  uterus  is  not  emptied  artificially,  it  as  a  rule  expels  the 
mole  spontaneously  at  about  the  end  of  the  fourth  month.  If 
expulsion  is  complete,  the  patient  may  then  return  to  her  usual 
condition  of  health.  On  the  other  hand,  the  haemorrhages  which 
occur  prior  to  or  during  its  expulsion  are  sometimes  so  severe  as 
to  bring  about  the  death  of  the  patient,  especially  if  they  are 
associated  with  a  partial  emptying  of  the  uterus  and  decomposi- 
tion of  the  remaining  portion  of  mole.  In  cases  of  so-called 
malignant  mole,  in  which  the  degenerated  villi  have  grown  out 
into  the  uterine  wall,  rupture  of  the  uterus  may  occur  during  the 
*   Union  Med.,  1873,  p.  275. 


494 


THE  PATHOLOGY  OF  PREGNANCY 


process  of  spontaneous  expulsion,  or  during  the  artificial  removal 
of  the  mole.     If  the  mole  extends  through  the  uterine  wall  into 


Fig.  265. — Malignant  Form  of  Vesicular  Mole,  growing  through 
Uterine  Wall. 

A,  Uterine  sinuses  into  which  the  mole  has  grown  ;  B,  sinuses  in  the  decidua 
serotina  ;  C,  os  internum;  D,  cervix;  E,  growth  commencing  to  invade 
the  uterine  wall.     (Bumm.) 


the   peritoneal    cavity,   the   subsequent    history  will    be    that   of 
malignant  disease  of  the  peritoneum  {v.  Fig.  265). 


THE  TREATMENT  OF  VESICULAR  MOLE  495 

Diagnosis. — The  diagnosis  of  the  case  is  made  from  the  following 
points  : — 

(1)  A  history  of  pregnancy,  accompanied  by  many  of  the 
subjective  and  objective  signs. 

(2)  Altered  relations  between  the  size  of  the  uterus  and  the 
assumed  period  of  pregnancy. 

(3)  Alterations  in  the  consistency  of  the  uterus. 

(4)  The  peculiar  watery  nature  of  the  discharge.  The  presence 
of  small  grape-like  cysts  in  it  is  pathognomonic. 

It  is,  however,  by  no  means  easy  to  arrive  at  once  at  a  definite 
diagnosis  unless  one  is  fortunate  enough  to  find  the  characteristic 
cysts.  In  many  cases,  it  is  necessary  to  wait  and  watch  the 
patient  from  day  to  day,  unless  the  amount  of  haemorrhage  which 
is  occurring  is  excessive,  when  immediate  interference  will  be 
necessary  whether  we  are  dealing  with  a  vesicular  mole  or  not. 
It  has  been  suggested  that,  in  doubtful  cases,  examination  with 
the  X  rays  would  clear  up  the  nature  of  the  case  by  showing  the 
presence  or  absence  of  a  foetus  (Ouvry*).  This  may  perhaps  be 
found  to  be  the  case,  but  on  the  other  hand  the  relative  opacity 
of  a  vesicular  mole  will  probably  be  found  to  be  as  great  as 
that  of  the  embryo  or  the  early  foetus,  and,  even  if  there  is  some 
difference  in  the  relative  opacities,  the  amount  of  tissue  through 
which  the  rays  have  to  pass  is  so  considerable  that  it  would  be 
difficult  to  detect  it. 

Treatment. — There  is  only  one  line  of  treatment  to  be  adopted 
in  this  condition,  and  that  is  to  empty  the  uterus  as  soon  as  the 
existence  of  a  mole  is  recognised.  As  it  is  impossible  to  foretell 
whether  the  uterine  wall  is  infiltrated  or  not,  it  is  necessary  to 
avoid  all  manipulations  which  could  cause  rupture.  For  this 
reason,  the  practice  of  removing  the  mole  with  the  curette  must 
be  condemned,  on  account  of  the  ease  with  which  the  curette  can 
perforate  a  diseased  uterine  wall.  Perhaps,  the  best  practice  to 
follow  consists  in  dilating  the  cervix  with  Hegar's  dilators,  as  far 
as  can  be  done  without  lacerating  it,  i.e.,  up  to  about  No.  16 
or  No.  20,  and  then  in  introducing  the  largest  sized  hydrostatic 
dilator  which  can  be  got  through  the  canal.  This  is  allowed  to 
remain  in  situ  until  it  is  expelled  by  the  uterine  contractions,  or  if 
the  contractions  do  not  occur  within  twelve  hours  after  the 
insertion  of  the  dilator,  the  latter  is  gently  pulled  through  the 
cervix  by  continuous  traction  applied  to  it,  as  will  be  described 
in  another  place.  In  most  cases,  this  procedure  will  induce 
labour,  and  the  contractions  of  the  uterus  will  then  expel  the  mole. 
If  they  do  not  do  so,  the  finger  or  the  hand — according  to  the  size 
which  the  uterus  has  attained — is  passed  into  the  uterus,  and  the 
mole  is  gently  detached  from  the  uterine  wall  and  removed  in  a 
manner  very  similar  to  that  adopted  in  the  case  of  a  retained 
adherent  placenta.  After  it  has  been  removed,  the  uterus  is 
douched  out  with  hot  water,  and  firmly  tamponned  with  iodoform 
*   '  Etude  de  la  Mole  Hydatidiforme,'  These  de  Paris,  1897. 


496  THE  PATHOLOGY  OF  PREGNANCY 

gauze.  The  introduction  of  the  latter  is  especially  advisable  in 
these  cases  not  only  with  the  object  of  checking  haemorrhage,  but 
in  order  to  bring  away  completely  the  numerous  small  fragments 
which  have  been  left  behind. 

In  some  cases,  it  will  be  found  that  a  recurrence  of  the 
haemorrhage  occurs  in  from  three  to  six  weeks.  Such  a  condition 
is  due  to  the  retention  of  small  portions  of  the  mole,  and  will 
only  be  cured  by  their  removal.  As  the  uterus  has  by  this 
time  become  considerably  reduced  in  size,  it  may  with  safety 
be  curetted  and  plugged  with  iodoform  gauze.  If  possible,  the 
cavity  should  be  again  explored  with  the  finger,  in  order  to  eliminate 
the  possibility  of  the  malignant  form  of  mole,  and  if  the  discharge 
persists  even  after  the  curetting,  this  step  is  essential.  The  reason 
for  this  will  be  more  fully  appreciated  when  deciduoma  malignum 
and  its  connection  with  vesicular  mole  has  been  discussed.  If 
the  malignant  form  of  mole  is  diagnosed,  the  uterus  must  be 
immediately  removed.  This  procedure  will  perhaps  be  best 
carried  out  by  the  abdominal  route,  as  the  extreme  softness  of  the 
uterine  tissue  renders  it  difficult  to  draw  it  down  in  the  manner 
necessary  in  vaginal  hysterectomy. 

Prognosis. — Vesicular  mole,  if  recognised  in  time  and  re- 
moved with  proper  aseptic  precautions,  need  not  be  regarded  as 
a  very  dangerous  condition.  On  the  other  hand,  its  dangers,  if 
allowed  to  remain,  are  considerable.  The  patient  may  succumb 
to  the  continued  loss  of  blood,  or  she  may  be  so  weakened  by  it 
that  she  is  unable  to  stand  the  emptying  of  the  uterus,  and  the 
additional  loss  of  blood  which  of  necessity  accompanies  this 
procedure.  Further,  her  condition  predisposes  to  the  occurrence 
of  septic  infection.  If  the  mole  perforates  the  uterus,  death  may 
result  from  peritonitis  or  from  its  subsequent  malignant  growth 
in  the  abdominal  cavity.  The  various  minor  diseases  which 
accompany  pregnancy,  are  said  to  be  sometimes  aggravated  in 
the  case  of  a  mole,  especially  vomiting  and  pregnancy  kidney, 
and  their  presence  of  necessity  renders  the  condition  of  the 
patient  more  serious. 

CHORION-EPITHELIOMA  OR  DECIDUOMA 

MALIGNUM 

The  condition,  which  we  are  now  about  to  describe,  is  one 
which,  so  far  as  its  aetiology  and  histogenesis  are  concerned, 
was  up  to  the  last  few  years  most  obscure.  As  we  shall  presently 
see,  a  large  number  of  theories  were  brought  forward  to  account 
for  its  development,  and  according  as  one  or  other  was  adopted 
a  different  name  was  given  to  it.  Unfortunately,  each  of  these 
names  implies  a  particular  aetiology,  and,  consequently,  is  more 
or  less  meaningless  unless  we  at  the  same  time  adopt  such  an 
aetiology.     The  result  of  this  was  that  for  a  long  time  there  was 


HISTOGENESIS  OF  CHORION-EPITHELIOMA  497 

no  term  for  the  condition  which  could  be  logically  accepted  by 
all  observers.  The  term  chorion-epithelioma  may,  however,  now 
be  finally  adopted,  and  although  long  use  may  give  some  sanction 
to  the  use  of  the  term  deciduoma  malignum,  so  far  as  this 
implies  that  the  new  growth  arises  from  the  decidua  it  is  a 
complete  misnomer. 

By  the  terms  chorion-epithelioma  and  deciduoma  malignum, 
we  mean  a  new  growth  which  is  met  with  in  the  uterus  as 
a  result  of  pregnancy,  which  rapidly  involves  the  greater  part 
of  or  the  entire  uterus,  which  causes  metastases  in  other  organs, 
and  which  almost  always  rapidly  brings  about  the  death  of  the 
patient. 

Histogenesis .* — Speaking  generally,  the  different  schools  of 
opinion  regarding  the  origin  of  this  interesting  growth  may  be 
divided  into  two  groups  : — first,  those  which  consider  that  the 
growth  is  directly  due  to  a  pre-existing  pregnancy;  and,  secondly, 
those  which  consider  the  growth  to  be  a  pre-existing  sarcoma 
of  the  uterus.  If  the  second  opinion  is  the  correct  one,  the 
histogenesis  of  the  growth  calls  for  no  special  attention  ;  if,  on 
the  contrary,  the  first  opinion  is  the  correct  one,  puzzling  problems 
offer  themselves  for  solution. 

If  the  growth  is  the  direct  result  of  pregnancy,  it  is  possible 
that  it  should  arise  from  the  decidua  ;  from  the  epithelial  coverings 
of  the  chorionic  villi ;  or  from  the  stroma  of  the  chorionic  villi. 

Origin  from  the  Decidua. — Sanger,!  who  was  the  first  to 
describe  the  growth,  considered  that  it  originated  in  the  decidua, 
and  consequently  applied  the  term  '  deciduoma  malignum  '  to  it. 
Subsequently,  as  a  result  of  an  opinion  that  it  originated  in  the 
cellular  layer  of  the  decidua  he  altered  this  term  to  sarcoma 
deciduo-cellulare,  on  account  of  the  similarity  of  structure  between 
the  cells  of  the  growth  in  the  case  he  described  and  those  of  the 
cellular  layer  of  the  decidua,  the  only  difference  as  he  considered 
being  that  in  the  pathological  growth  the  nuclei  were  larger  and 
the  protoplasmic  ring  narrower. 

Of  late,  in  consequence  of  the  examination  of  further  speci- 
mens, Sanger  has  agreed  to  accept  the  explanation  of  Marchand, 
to  which  Ave  shall  next  refer,  but  with  the  reservation  that  the 
possibility  of  the  formation  of  sarcoma  cells  out  of  decidual  cells 
cannot  be  excluded  in  view  of  his  first  case,  which  does  not 
correspond  in  all  points  with  those  described  by  Marchand. 

Origin  from  the  Epithelial  Coverings  of  the  Chorionic  Villi. — 
Under  this  heading  are  included  several  radically  different  views 
arising    out     of    the     uncertainty    as    to    the    origin    of    these 

*  The  following  short  resume  of  the  histogenesis  of  chorion-epithelioma  is 
largely  drawn  from  papers  by  Haultain,  Brit.  Gyncecol.  Journ.,  August,  1899; 
Smyly,  Trans.  Roy.  Acad.  Med.,  Ireland,  1900;  and  Whitridge  Williams,  Johns 
Hopkins  Hospital  Reports,  vol.  iv.,  1893 ;  and  from  '  Ueber  das  maligne 
Chorionepitheliom,'  by  W.  Rissel,  Leipzig,  1903. 

t  Centralb.  f.  Gyn.,  1889,  p.  132  ;  Archiv  f.  Gyn.,  vol.  xliv.,  1893,  p.  89. 

32 


498  THE  PATHOLOGY  OF  PREGNANCY 

epithelial  layers,  and  more  particularly  of  the  outer  layer  or 
syncytium.  Now  that  the  discovery  of  the  Peters'  ovum  has 
in  great  part  cleared  up  the  origin  of  these  layers,  all  but  one 
of  these  views  disappear.  Still,  as  they  are  of  historical  interest 
they  may  be  shortly  described  :  — 

(i)  That  the  growth  is  derived  from  the  syncytium  alone,  and 
that  the  latter  is  a  maternal  structure  formed  from  the  uterine 
endometrium.  This  theory  was  first  adopted  by  Whitridge 
Williams,*  and  was  really  a  modification  of  that  originally  put 
forward  by  Sanger,  and  indeed  Williams  was  at  the  time  disposed 
to  accept  Sanger's  theory  as  accounting  for  the  histogenesis  of 
certain  cases.  He  has,  however,  now  also  accepted  Marchand's 
view.f 

(2)  That  the  growth  is  derived  from  the  syncytium  alone,  and 
that  the  latter  is  a  foetal  structure  formed  from  the  ectodermic 
layer.  This  theory  was  adopted  by  several  authorities  and 
notably  by  FraenkelJ:  and  Durante, §  and  on  this  account  the  term 
'syncytial,'  or  'ectodermic  epithelioma,'  has  been  applied  to  the 
growth.  Fraenkel  has,  however,  also  come  to  regard  Marchand's 
view  as  correct. 

(3)  That  the  growth  is  derived  from  both  the  syncytium  and 
Langhans'  layer,  and  that  the  syncytium  is  a  maternal  structure. 
This  theory  was  held  by  Gebhard,||  who,  in  consequence,  con- 
sidered the  growth  to  be  a  mixed  carcinoma  of  maternal  and 
foetal  structure.  It  does  not  appear  to  have  had  many  other 
supporters,  as  the  majority  of  those  who  consider  the  growth  to 
be  derived  from  both  epithelial  layers  also  adopted,  and  correctly, 
as  we  now  know,  the  foetal  origin  of  these  layers. 

(4)  That  the  growth  is  derived  from  both  epithelial  layers  and 
that  both  are  of  fcetal  origin.  This  view  was  introduced  by 
MarchandU  in  the  face  of  considerable  opposition,  and  was  sup- 
ported by  Haultain,**  and  in  turn  by  Williams.  It  was  at  first 
strongly  opposed  by  the  London  school  headed  by  Eden,  but  is 
now  almost  universally  accepted. 

Origin  from  the  Stroma  of  the  Chorionic  Villi. — This  view  was 
brought  forward  by  Gottschalk,i  t  who  consequently  termed  the 
growth  a  chorio-sarcoma.  It  received  little  or  no  support,  and 
Gottschalk  has  now  accepted  Marchand's  view. 

The  view  that  the  growth  is  a  pre-existing  sarcoma  of  the 
uterus  was,  and  is  still,  strongly  supported  by  Veit.;]:^  He  admits 
that  the  sarcoma  is  modified  by  the  existence  of  pregnancy,  but 
states  as  a  general   law  that  disease  of  the  mother   is   always 

*  Op.  tit.  f  'Obstetrics,'  p.  491.     New  York,  Appleton  and  Co.,  1903. 

X  Archiv  f.  Gyn.,  vol.  xlix.,  Hft.  iii. ,  1895. 

§  Rev.  Med.  de  la  Suisse  Romande,  1896,  p.  686. 

||  Zeitschrift,  vol.  xxxvii.,  p.  480. 

IT  Monat.  f.  Geb.   u.  Gyn.,  1895,  v°l-  *■■  P-  513  •  Berlin  Med.   Wochen.,  1894, 
p.  813  ;  1898,  p.  11. 
**  Op.  tit.  ft  Archiv  f.  Gyn.,  vol.  xlvi.,  p.  1 ;  and  Ibid.,  vol.  li.,  p.  56. 

t+  Veit,  .'  Handbuch  der  Gyn.,'  1899,  iii.,  pp.535-596. 


HISTOGENESIS  OF  CHORION-EPITHELIOMA  499 

primary  and  cannot  arise  from  the  foetus.  He  admits  that  no 
case  has  been  recorded  of  the  implantation  of  an  ovum  on 
a  carcinomatous  endometrium,  but  considers  that  in  nodular 
sarcoma  the  endometrium  resembles  that  in  a  myomatous  uterus, 
and  that  as  pregnancy  may  occur  in  the  one,  it  may  occur  in  the 
other.  He  considers  further  that  it  is  impossible  to  regard  all 
protoplasmic  masses  as  true  syncitium  derived  from  the  outer 
layer  of  the  villi,  and  thinks  it  more  probable  that  in  normal 
pregnancy  other  cells,  such  as  the  epithelium  of  the  endometrium, 
often  take  on  a  syncitial  form,  and  that  in  consequence  it  is 
impossible  to  regard  the  syncitium — using  the  term  in  this  wider 
sense — as  a  distinct  tissue,  but  rather  as  a  stage  in  the  develop- 
ment of  certain  cells.  Accordingly,  he  thinks,  a  sarcoma  may, 
under  the  influence  of  pregnancy,  come  to  resemble  the  syncitium, 
and  that  therefore  the  disease  should  be  regarded  as  a  process  by 
which,  under  the  influence  of  pregnancy,  certain  cells  take  on  a 
syncitial  character.  This  view  was  for  a  considerable  time  shared 
more  or  less  completely  by  many  British  obstetricians  and 
pathologists. 

We  cannot  see  that  Veit's  general  law  regarding  the  primarily 
maternal  origin  of  maternal  disease  need — even  if  true — neces- 
sarily contradict  Marchand's  view.  The  invasion  of  the  maternal 
tissues  by  an  overgrowth  of  foetal  epiblast  may  be  due  to  the  posses- 
sion of  excessive  powers  of  growth,  and  special  powers  of  over- 
coming the  resistance  of  the  uterine  tissues,  or  it  may  be  due  to 
lessened  resistance  on  the  part  of  these  tissues.  In  the  former 
case,  special  powers  of  growth  and  of  invasion  may  quite  legiti- 
mately be  conceived  to  be  due  to  the  effect  of  some  irritant  acting 
on  the  epiblast,  and  this  irritant  must  of  necessity  be  maternal. 
In  the  second  case,  the  diminished  resistance  is  also  maternal. 

Veit's  view  was  adopted  by  the  Obstetrical  Society  of  London 
in  1896,  and  constituted  for  several  years  the  so-called  '  English' 
view  of  the  origin  of  chorio-epithelioma.  This  expression  of 
opinion  was,  as  Teacher  says  in  his  now  classical  paper,  a 
stumbling-block  to  advances  towards  the  better  conception  of  the 
pathology  of  the  growth  for  many  years,  and  cramped  the  opinion 
of  many  who  might  otherwise  have  endeavoured  to  advance  our 
knowledge.  So  recently  as  1901,  the  author  was  adversely 
criticised  in  a  review  for  giving  special  notice  in  another  work  *  to 
'  deciduoma  malignum,'  seeing  that  '  in  the  majority  of  cases  the 
growth  is  simply  a  large-celled  sarcoma,  which  may  or  may  not  be 
associated  with  pregnancy.' 

As  we  have  already  mentioned,  Marchand's  view  is  now 
received  by  almost  every  authority  of  importance  with  the  ex- 
ception of  Veit.  It  was  founded— to  quote  Teacher — on  the 
anatomical  and  physiological  resemblances  between  the  chorionic 
epithelium  and  the  tumour  tissues,  and  has  been  fully  supported 
by   a    re-investigation    of   the    pathology    of   vesicular    mole,   in 

*  '  A  Short  Practice  of  Gynaecology.'     London,  J.  and  A.  Churchill,  1901. 

32—2 


500 


THE  PATHOLOGY  OF  PREGNANCY 


which  it  was  shown  that  hypertrophy  of  the  chorionic  epithelium 
is  a  constant  feature.  Finally,  the  finding  of  the  Peters'  ovum 
definitely  demonstrated  the  foetal  origin  of  the  two  layers  of  the 
chorionic  epithelium. 

The  growing  trophoblast,  as  was  long  suspected,  possesses  the 
power  of  invading  and  destroying  the  maternal  tissues  up  to  a 
certain  point,  where  apparently  the  resistance  of  the  maternal 
tissues  become  sufficient  to  check  this  action  and  an  equilibrium 
is  established.  In  the  case  of  the  simple  vesicular  mole,  the 
epithelial  layers  proliferate,  but  their  power  of  maternal  invasion 
is  not  increased.  In  the  malignant  vesicular  mole,  all  the  elements 
of  the  villi  proliferate  and  invade  the  uterine  wall,  the  epithelial 
layer,  however,  being  apparently  the  active  agent  of  destruction. 
In  the  pure  chorion-epithelioma,  the  epithelial  layers  alone  pro- 
liferate and  invade  the  uterine  wall,  and  no  trace  of  the  meso- 
blastic  core  of  the  villus  is  found.  Between  this  true  chorion- 
epithelioma  and  the  malignant  form  of  vesicular  mole,  tumours 
are  found  consisting  of  syncytium  and  cells  of  Langhans'  layer, 
through  which  are  scattered  a  few  villi  with  or  without  prolifera- 
tion of  their  mesoblastic  core.  These  intermediate  forms  serve  to 
emphasise  the  close  connection  between  the  malignant  vesicular 
mole  and  the  chorion-epithelioma,  if  indeed  they  do  not  render 
it  impossible  to  draw  a  hard  distinction  between  them,  and 
also  render  still  more  clear  the  epiblastic  origin  of  the  chorion- 
epithelioma. 

Clinically,  the  connection  between  vesicular  mole  and  chorion- 
epithelioma  is  as  close  as  the  investigations  of  Marchand  and 
Fraenkel  into  their  histological  character  would  lead  one  to 
expect.  In  cases  of  vesicular  mole,  one  element  at  least  in  the 
production  of  a  chorion-epithelioma  is  present  in  the  prolifera- 
tion of  the  chorionic  epithelium,  and  it  is  reasonable  to  suppose 
that  if  a  lessened  maternal  resistance  to  chorionic  invasion  is  also 
present,  a  chorion-epithelioma  will  also  result.  Haultain  has 
collected  the  statistics  of  ninety  cases  of  the  latter  condition, 
forty-nine  of  which  followed  the  expulsion  of  a  vesicular  mole. 

Pathological  Anatomy.  —  The  growth  at  first  appears  as  a 
pedunculated  or  sessile  tumour,  varying  in  size  between  that  of  a 
pea  and  that  of  an  orange.  It  is  attached  to  the  uterine  wall  and 
bulges  somewhat  into  the  uterine  cavity.  In  consistency,  it  is 
friable  and  easily  broken  down  by  the  curette ;  it  is  grayish  in 
colour  and  marked  here  and  there  over  its  surface  by  hasmor- 
rhagic  areas.  As  it  grows,  it  extends  into  the  uterine  muscle, 
and  spreads  along  it  in  isolated  nodules  over  which  the  mucous 
membrane  is  at  first  unaltered.  Finally,  however,  the  mucous 
membrane  lining  a  great  part  of  the  cavity  becomes  involved  and 
destroyed.  The  entire  cavity  then  becomes  filled  by  a  fungating 
mass  of  placenta-like  substance,  which  breaks  down  readily  under 
the  finger  or  curette,  and  bleeds  freely.  Metastatic  growths  are 
the  result  of  emboli  carried  along  in  the  blood-stream,  or  of  the 


PATHOLOGICAL  ANATOMY  OF  CHORION-EPITHELIOMA     501 

direct  implantation  of  fragments  of  the  growth  into  wound- 
surfaces.  They  are  found  most  commonly  in  the  lungs  and 
vagina,  and  also  in  the  broad  ligaments,  and  in  the  liver,  heart, 
and  other  viscera. 

The  histological  character  of  the  growth  demands  some  con- 
sideration. In  many  of  the  recorded  cases,  differences  of  structure 
have  been  found  ;  still,  on  the  whole,  there  are  certain  character- 
istics which  can  be  found  in  every  or  in  almost  every  case. 
Speaking  generally,  the  growth  is  found  to  be  composed  of 
blood-clot,  two  varieties  of  cellular  elements  and  chorionic  villi. 


!# 


•.V 


Fig.  266. — Chorion-Epithelioma,  showing  Alveolar  Arrangement  of 
Primary  Tumour,      x  60.     (Williams.) 

Haultain    describes   the    cellular    elements    as    follows :  —  The 
cellular  elements  are  of  two  types  : — 

(1)  Large  polyhedral  cells,  which  stain  lightly,  and  wrhose  large 
nuclei  show  a  wide  intra-nuclear  network. 

(2)  Multinucleated  deeply-staining  protoplasmic  masses  of  all 
varieties  of  shape,  whose  nuclei  are  extremely  rich  in  chromatin 
and  show  no  wide  intra-nuclear  network  as  in  the  other  cells. 

Both  varieties  of  elements  show  a  marked  tendency  to  a  retrac- 
tion of  their  protoplasm  and  to  vacuolation.  Mitotic  figures  are 
frequently  observed  in  the  individual  cells,  but  nowhere  in  the 
protoplasmic  masses.  The  relation  of  these  two  types  of  cells 
varies  greatly  ;  in  some  cases  it  appears  as  if  groups  of  individual 
cells  were  confined  in  alveoli  formed  by  processes  of  nucleated 
protoplasm.     This  is  most  apparent  when  in  close  relation  with 


502  THE  PATHOLOGY  OF  PREGNANCY 

the  chorionic  villi.  As  one  proceeds  further  from  the  villi,  the 
cells  and  protoplasmic  masses  are  arranged  indefinitely.  The 
individual  cells,  in  some  places,  are  much  in  excess  of  the  proto- 
plasmic masses,  while  in  others  the  latter  only  are  to  be  dis- 
tinguished. Nowhere  is  there  much  evidence  of  inter-cellular 
substance  or  bloodvessels,  although  free  blood  is  intimately 
mixed  with  the  cells,  and  is  also  found  in  the  vacuoles  in  their 
substance.  Extending  into  the  muscle  can  be  seen  clumps  of 
both  type  of  cells,  apparently  following  the  peri-vascular  lymph- 


** 

./af- 

*:  &     I  4  ft.  Cfi» 

* 

»                            ;§? 

;ji.r;; 

^     jfe^®-  "■         ^-5-    •  Sggj -J5  •«*•"-.'    ^- 

\  '  ■-  -S 

'.'  £l  ■*      '  '          jtf?$*#* 

0^5^ 

.' 


>,#" 


..  e}?v 


Fig.  267. — Chorion-Epithelioma,  showing   Syncytial   Masses   invading 
a  Venous  Channel.     (Williams.) 

spaces,  while,  throughout,  individual  cells  may  be  seen  finding 
their  way  indiscriminately,  with  a  special  tendency  to  penetrate 
the  venous  sinuses  and  engraft  themselves  on  the  interior  of  their 
walls,  where  they  continue  to  proliferate. 

On  section  of  the  tumour,  three  areas  may  be  microscopically 
determined  : — 

(1)  A  sub-mucous  or  peripheral  area,  which  forms  the  main 
bulk  of  the  tumour  mass,  and  is  necrotic  in  character,  composed 
of  fibrin  and  cellular  elements  in  all  stages  of  degeneration. 


DIAGNOSIS  OF  CHORION-EPITHELIOMA  503 

(2)  A  cellular  layer  or  tumour  proper,  which  is  composed 
entirely  of  actively  proliferating  cellular  elements  and  chorionic 
villi  mixed  with  free  uncoagulated  blood. 

(3)  An  area  of  infiltration  in  which  may  be  seen  cells  and 
protoplasmic  masses,  isolated  and  in  groups,  insinuating  them- 
selves into  the  blood  channels,  and  surrounded  by  the  muscle 
fibres  of  the  uterine  wall.  In  this  area,  chorionic  villi  are  not 
found. 

The  foregoing  description,  in  Haultain's  words,  is  based  upon 
the  careful  examination  of  a  case  with  which  he  met,  and  agrees 
in  most  particulars  with  the  descriptions  published  by  other 
observers.  A  third  type  of  cell  was  also  described  by  Marchand 
and  termed  a  '  chorion  wandering  cell!  It  is  found  as  a  kind  of 
advance  guard  in  the  area  of  infiltration  penetrating  amongst  the 
muscle  fibre,  while  the  growth  proper  spreads  along  in  the  blood 
sinuses.  The  plasmodial  masses  form  the  characteristic  element 
of  the  growth,  and  can  be  found  in  every  case. 

Symptoms. — The  earliest  symptoms  of  chorion-epithelioma  con- 
sist in  a  recurrence  of  irregular  haemorrhages  within  a  few  weeks 
of  the  occurrence  of  abortion  or  the  expulsion  of  a  vesicular 
mole.  In  a  few  cases  the  haemorrhage  has  not  commenced  until 
some  months  after  the  abortion,  but  this  is  quite  exceptional,  and, 
as  Haultain  suggests,  it  is  possible  that  in  the  interval  the  patient 
has  had  another  abortion.  The  haemorrhage,  is,  as  a  rule,  con- 
siderable in  amount.  In  Smyly's  case,  as  in  others  recorded,  it 
was  so  severe  that  the  patient  was  on  the  point  of  death  from 
syncope.  In  the  intervals  between  the  attacks  of  haemorrhage, 
there  is  a  more  or  less  foetid,  watery,  and  blood-stained  discharge. 
The  patient's  general  condition  becomes  worse  each  day  as 
a  result  of  the  previous  haemorrhages  ;  cachexia  is  caused  by 
absorption  of  ptomaines  from  the  fungating  growth,  and  by  the 
occurrence  of  metastases  in  a  later  stage.  Her  temperature  rises 
as  soon  as  intra-uterine  decomposition  occurs,  and  assumes  a 
hectic  type.  Usually,  the  first  symptom  of  metastases  is  the 
occurrence  of  a  persistent  cough  due  to  extension  to  the  lungs, 
auscultation  of  which  will  reveal  the  existence  of  patches  of 
pneumonia. 

On  vaginal  examination,  the  cervix  is  found  to  be  sometimes 
closed  and  sometimes  patulous.  If  the  finger  is  passed  into  the 
uterine  cavity,  a  fungating  growth  is  felt  which  more  or  less  fills 
the  cavity  according  to  the  stage  it  has  reached,  and  which  breaks 
down  readily  under  the  finger.  The  body  of  the  uterus  also 
enlarges  rapidly  in  proportion  to  the  growth  of  the  tumour,  and 
may  rise  above  the  level  of  the  pelvic  brim. 

Diagnosis. — The  diagnosis  of  this  condition  is  not  difficult,  once 
our  attention  is  directed  to  the  possibility  of  its  occurrence.  It 
cannot  be  too  strongly  insisted  upon  that,  in  all  cases  in  which 
haemorrhage  recurs  after  pregnancy,  the  patient  should  be  care- 
fully examined  bi- manually.     If  the  uterus  is  not  enlarged,  it  will 


504  THE  PATHOLOGY  OF  PREGNANCY 

be  sufficient  to  curette  it  and  examine  the  scrapings  microscopic- 
ally, but,  if  it  is  enlarged,  the  finger  should  be  passed  into  it  and 
the  cavity  explored.  A  chorion-epithelioma  may,  in  an  early  stage, 
be  confounded  with  a  small  sub-mucous  myoma  ;  a  distinction  can 
be  made  by  noting  the  ease  with  which  the  growth  is  broken 
down  with  the  finger-nail  or  curette  in  the  former  case.  In  a 
later  stage,  it  may  be  mistaken  for  portions  of  retained  and 
decomposing  placental  tissue.  As  the  retention  of  such  fragments 
is  always  possible  after  abortion  or  labour,  this  is  a  very  natural 
and  probable  mistake  to  make.  It  can,  however,  be  guarded 
against,  first,  by  noting  that  it  is  impossible  to  remove  all  the 
f ungating  mass  which  fills  the  uterine  cavity  in  the  case  of  a 
chorion-epithelioma,  while  this  can  as  a  rule  be  easily  done  in 
the  case  of  retained  portions  of  placenta ;  and,  secondly,  by  sub- 
mitting the  removed  fragments  to  microscopical  examination  at 
the  hands  of  a  competent  microscopist.  In  selecting  portions  for 
microscopical  examination,  the  superficial  parts  of  the  growth 
must  be  avoided,  as  these  usually  consist  of  little  but  necrosed 
tissue  and  blood-clot.  The  characteristic  appearances  will  only 
be  found  when  the  removed  portion  comes  from  the  neighbour- 
hood of  the  spreading  edge  of  the  growth. 

Occasionally,  it  happens  that  a  case  occurs  in  which  the  usual 
haemorrhages  are  absent,  as  in  one  recorded  by  Williams,  where 
the  first  evidence  of  the  disease  was  furnished  by  metastatic 
deposits  in  the  vagina.  The  absence,  of  haemorrhage  in  such 
cases  is  probably  due  to  the  depth  at  which  the  growth  starts 
in  the  uterine  wall.  Here,  early  diagnosis  is  practically  im- 
possible, but  it  is  satisfactory  to  know  that,  sometimes  at  any 
rate,  after  extirpation  of  the  uterus  the  vaginal  or  other 
metastases  may  disappear,  being  apparently  killed  by  the  clotting 
round  them  of  the  haemorrhage  to  which  they  gave  rise.  The 
cases  recorded  by  Lonnberg  and  Manheimer,*  and  Freund,i  are 
notable  instances  of  this.  The  vaginal  metastases  first  occur  as 
soft,  purplish  swellings,  which  rapidly  ulcerate  on  the  surface  and 
break  down,  leaving  behind  an  irregular  ulcer.  Such  metastases 
may  be  found  not  only  on  the  vaginal  walls,  but  also  on  the 
vulva. 

Treatment. — There  is  only  one  treatment  applicable  to  chorion- 
epithelioma.  It  is  a  malignant  growth,  and  must  be  treated 
accordingly.  Complete  extirpation  of  the  uterus  alone  affords 
any  hope  of  cure,  and  must  be  adopted  in  every  case,  as  soon  as 
the  condition  is  recognised.  The  presence  of  metastases  is  not  a 
contra-indication  to  operation,  which  should  be  performed  when- 
ever the  condition  of  the  patient  offers  a  hope  that  she  will  be 
able  to  stand  the  attendant  shock. 

Prognosis.  —  The  prognosis  of  chorion -epithelioma  when  not 
operated  upon  is,  so  far  as  we  at  present  know,  absolutely  bad, 

*  Centralb.  f.  Gyn.,  1896,  p.  474. 

f  Zeits.  f.  Geb.  u.  Gyn.,  1896,  vol.  xxiv.,  Hft.  2. 


II YDR  AMNIOS  505 

death  occurring  within  a  period  varying  from  some  weeks  to  six 
months,  according  to  the  rapidity  with  which  the  tumour  grows. 
Death  may  be  directly  due  to  haemorrhage,  to  septic  absorption,  or 
to  metastatic  pneumonia.  If  the  uterus  is  completely  removed 
before  the  occurrence  of  metastases,  the  prognosis  is  good. 
Haultain  found  thirty  cures  amongst  ninety  cases,  and  many  of 
those  which  terminated  fatally  were  not  operated  upon.  As  has 
been  already  mentioned,  the  presence  of  metastases  is  not  a 
contra-indication  to  operation.  Not  only  have  cases  in  which 
there  were  deposits  in  the  vagina  been  cured,  but  also  cases  in 
which  there  were  deposits  in  the  ovary  (Cazin*),  and  in  which 
there  was  evidence  of  pulmonary  metastases  as  shown  by  the 
presence  of  hemorrhagic  sputum,  and  other  symptoms  (Chrobakj 
and  Von  Franque]).  Such  cases  are  accounted  for,  according  to 
Haultain,  by  the  peculiar  character  of  the  malignant  cells, 
which  apparently  grow  freely  only  in  circulating  blood,  and 
rapidly  degenerate  and  die  in  extravasated  blood.  It  is  possible, 
therefore,  that  the  cells  in  the  metastases  may,  by  becoming  as  it 
were  choked  in  the  haemorrhage  to  which  they  give  rise,  be  cut 
off  from  that  free  circulation  which  is  so  essential  to  their  con- 
tinued activity,  and  rapidly  die. 


HYDRAMNIOS 

Hydrops  amnii  or  hydramnios  is  the  term  applied  to  an 
excessive  quantity  of  liquor  amnii.  It  is  difficult  to  say  what  is 
the  exact  amount  of  fluid  which  constitutes  hydramnios,  but  in 
practice  we  may  consider  any  quantity  up  to  two  pints  at  full 
term  to  be  not  excessive,  and  over  two  pints  to  be  excessive. 
Cases  in  which  the  uterus  contained  as  much  as  twenty  pints,  or 
even  more,  have  been  met  with,  and  to  this  condition  the  term 
polyhydramnios  is  applied. 

Frequency. — The  relative  frequency  of  hydramnios  is  said  to  be 
from  1  in  100  to  1  in  150  cases.  At  the  Rotunda  Hospital, 
hydramnios  was  found  109  times  in  20,000  cases,  a  proportion 
of  1  in  183-58. 

Varieties. — Two  forms  of  hydramnios  are  met  with,  an  acute 
form  which  comes  on  very  rapidly,  perhaps,  in  the  course  of  a 
single  night,  and  a  chronic  form  in  which  the  increased  quantity 
of  liquor  amnii  gradually  accumulates  during  the  second  half  of 
pregnancy. 

ALtiology. — Strictly  speaking,  hydramnios  is  not  a  definite 
disease,  but  rather  a  symptom  of  a  considerable  number  of  widely 
differing  pathological  conditions  present  in  either  the  ovum  or  the 
mother.     We  may  then  classify  the  various  causes  of  hydramnios 

*  La  Gynecologic,  1896,  p.  15. 

f  Centralb.  f.  Gyn.,  1896,  p.  1281. 

J  Zeits-  f.  Geb.  u.  Gyn.,  1896,  vol.  xxiv.,  Hft.  2. 


506  THE  PATHOLOGY  OF  PREGNANCY 

into  two  groups  : — maternal  causes,  and  ovular  causes.  The 
principal  maternal  pathological  conditions  which  may  be 
associated  with  hydramnios  are  renal  disease,  cardiac  disease, 
and  anaemia  and  hydraemia.  The  manner  in  which  they  act  is 
obscure.  Maternal  syphilis  may  also  be  a  cause,  but  whether  it 
acts  directly  or — as  is  more  probable — by  producing  various 
foetal  lesions  is  uncertain. 

The  principal  foetal  conditions  which  are  associated  with 
hydramnios  are  as  follows  : — 

(i)  Multiple  pregnancy,  particularly  in  the  case  of  uni-ovular 
twins.  In  such  cases  as  a  rule  only  one  amniotic  sac  is  affected, 
and  according  to  McClintock  it  is  usually  the  second  sac.  The 
reason  for  the  occurrence  of  hydramnios  in  these  cases  is  obscure. 
It  has  been  suggested  that  on  account  of  the  communication 
between  the  two  foetal  circulations,  the  blood-pressure  in  one 
foetus  may  be  greater  than  that  in  the  other,  and  thus  a 
circulatory  stasis  be  produced  in  the  latter  (Frankenhauser), 
this  stasis  in  turn  causing  transudation  from  the  blood-vessels. 
The  acute  form  of  hydramnios  is  most  frequently  met  with  in 
cases  of  twins. 

(2)  Foetal  malformations. — The  most  commonly  found  foetal 
malformations  are  anencephalus,  hydrocephalus,  and  spina  bifida. 
Hydramnios  is  also  found  in  association  with  almost  every 
form  of  foetal  intra- uterine  lesion,  and  especially,  perhaps,  in  the 
case  of  lesions  that  are  dependent  upon  syphilis.  It  has  been 
suggested  that  in  cases  in  which  the  covering  of  the  brain  is 
deficient,  the  hydramnios  is  due  to  polyuria  caused  by  the  stimula- 
tion of  cerebral  centres  by  pressure  or  by  contact  with  the  liquor 
amnii. 

(3)  Abnormalities  of  the  funis,  placenta  and  membranes. — In 
some  cases  of  hydramnios,  the  umbilical  cord  is  found  to  be 
longer  than  normal,  or  to  be  partially  constricted  by  twisting 
round  the  foetus,  by  knotting,  or  by  diminution  in  the  calibre  of  its 
vessels.  In  some  cases,  there  is  persistence  of  the  vessels  of 
Jungbluth* — a  capillary  plexus  which  has  been  described  in  early 
foetal  life  between  the  amnion  and  the  foetal  surface  of  the  placenta. 
In  other  cases  the  placenta  is  hypertrophied,  syphilitic,  or  studded 
with  infarctions.  Lastly,  in  a  few  cases,  there  is  a  thickened 
condition  of  the  membranes. 

In  view  of  the  numerous  and  widely  different  conditions  with 
which  hydramnios  is  associated,  it  is  difficult,  and  at  present 
impossible,  to  form  any  exact  idea  regarding  its  pathology. 
Ballantyne,f  who  discusses  the  subject  at  length,  points  out  that 
hydramnios  may  be  regarded  as  the  persistence  of  a  state  which 
is  physiological  in  the  early  months  of  pregnancy,  as  at  that  time 
the  liquor  amnii  weighs  more  than  either  the  foetus  or  the  placenta 
and  membranes,  or  that  it  may  be  a  symptom  of  various  antenatal 

*  Archiv  f.  Gyn.,  vol.  iv. ,  p.  554,  1872. 

f  '  Antenatal  Pathology  and  Hygiene,'  vol.  i,,  p.  405. 


THE  SYMPTOMS  OF  IIYDRAMNIOS  507 

pathological  conditions.  He  adopts,  as  will  most  men,  the  latter 
alternative,  and  considers  that  hydramnios  may  he  due  to  a 
chemical  irritant,  which  comes  from  the  mother  or  the  fcetus,  and 
which  excites  a  flow  of  lymph  or  serum  ;  it  may  be  due  to  increased 
pressure  in  the  umbilical  vein  and  its  branches,  arising  from  various 
foetal  diseases  and  deformities  ;  it  may  be  the  result  of  changes  in 
the  maternal  blood  which  allow  increased  transudation  ;  or  it 
may  possibly  represent  fcetal  urine  or  cerebro-spinal  fluid. 

Symptoms. — In  the  acute  form  of  hydramnios,  the  increase  in 
size  of  the  uterus  comes  on  very  rapidly,  perhaps  in  a  single 
night,  but  more  usually  in  from  a  couple  of  days  to  a  week.  The 
symptoms  are  similar  to  those  which  will  be  described  under  the 
chronic  form,  save  that  they  are,  as  a  rule,  more  severe  on  account 
of  the  rapidity  with  wrhich  the  increase  in  the  liquor  amnii 
occurs. 

In  the  chronic  form  of  hydramnios,  the  intensity  of  the  symptoms 
depends  upon  the  amount  of  fluid  present,  and  the  pressure  which 
results  upon  the  abdominal  and  thoracic  viscera.  The  abdomen 
becomes  considerably  distended,  and,  in  some  cases,  this  may 
reach  such  a  degree  that  the  patient  is  unable  to  leave  her  bed. 
The  usual  symptoms  are  due  to  pressure  upon  the  bladder 
causing  frequent  micturition,  upon  the  intestines  causing  con- 
stipation and  intestinal  atony,  upon  the  stomach  causing  nausea 
and  vomiting,  upon  the  heart  causing  palpitation,  and  in  extreme 
cases  threatened  or  even  actual  failure,  and  upon  the  lungs 
causing  dyspnoea.  The  action  of  the  kidneys  is  also  interfered 
with  and  the  quantity  of  urine  diminished,  while  albumen  and 
tube  casts  may  make  their  appearance  in  the  latter.  Lastly,  as 
a  result  of  pressure  upon  the  intra-abdominal  bloodvessels,  and 
the  vessels  of  the  abdominal  wall,  cedema  of  the  legs,  vulva,  and 
lower  part  of  the  abdominal  wall,  also  occurs.  If  the  pressure  is 
long  continued,  the  symptoms  may  become  so  acute  as  to  threaten 
the  life  of  the  patient. 

As  a  rule,  the  over-distension  of  the  uterus  determines  the  pre- 
mature onset  of  labour,  and  during  this  process  a  fresh  train  of 
complications  are  met  with.  The  over-distension  leads  to  atony 
of  the  uterine  muscle,  and,  in  consequence,  the  strength  of  the 
uterine  contractions  is  interfered  with,  and  labour  is  prolonged. 
This  prolongation  particularly  affects  the  first  and  the  third  stage, 
wThile  the  second  stage  may  be  precipitate.  The  cause  of  pre- 
cipitation in  this  stage  is  to  be  found  in  the  small  size  of  the 
fcetus — the  result  of  prematurity,  and  also,  perhaps,  of  the  par- 
ticular pathological  condition  which  gave  rise  to  the  excess  of 
liquor  amnii.  On  account  of  the  quantity  of  fluid  in  the  uterus, 
the  normal  adaptation  between  the  shape  of  the  latter  and  the 
shape  of  the  fcetus  is  altogether  lost,  and  abnormal  lies  and 
presentation  of  the  fcetus  are  of  common  occurrence.  Even  if  the 
vertex  presents,  the  head  remains  above  the  pelvic  brim  during 
the  first   stage,  and    does   not   fill    the   lower    uterine   segment. 


5o8  THE  PATHOLOGY  OF  PREGNANCY 

In  consequence  of  this,  the  membranes  protrude  unduly  into  the 
vagina  during  a  contraction,  and  rupture  prematurely.  The  ill 
effects  of  the  latter  occurrence  are  never  so  clearly  seen  as  in 
hydramnios.  Usually,  its  only  result  is  that  labour  is  prolonged 
owing  to  the  loss  of  the  dilating  action  of  the  bag  of  waters  In 
hydramnios,  however,  much  more  serious  consequences  follow, 
on  account  of  the  sudden  escape  of  the  large  collection  of 
fluid,  and  the  consequent  rapid  diminution  in  the  size  of  the 
uterus.  The  sudden  rush  of  liquor  amnii  may  sweep  down  a 
loop  of  the  umbilical  cord  or  a  limb  of  the  foetus,  and  at  the  same 
time  may  sweep  the  foetus  into  a  malposition,  if  it  was  not  already 
in  one ;  while  the  rapid  diminution  in  size  of  the  uterus  may 
cause  the  detachment  of  the  placenta.  Atony  of  the  uterus 
during  the  third  stage  may  lead  to  the  slow  detachment  or 
retention  of  the  placenta  and  to  post-partum  haemorrhage. 

Diagnosis. — -The  diagnosis  of  hydramnios  is  made  by  determining, 
first,  the  existence  of  pregnancy ;  then,  the  fact  that  the  abdominal 
tumour  is  formed  by  the  uterus ;  and,  finally,  that  the  increase  in 
size  in  the  latter  is  the  result  of  an  accumulation  of  fluid,  and  not 
of  multiple  pregnancy.  It  is  unnecessary  to  again  enter  into  the 
methods  of  diagnosing  the  existence  of  pregnancy,  inasmuch 
as  they  have  been  already  fully  discussed.  It  is  sometimes 
extremely  difficult  to  ascertain  definitely  that  the  abdominal 
tumour  is  formed  by  an  enlarged  pregnant  uterus.  It  may 
be  difficult  or  impossible  to  palpate  the  foetal  parts,  or  to  hear  the 
foetal  heart  on  account  of  the  interposition  of  fluid  between  the 
foetus  and  the  abdominal  wall,  and,  consequently,  all  that  is  felt 
is  a  large  cystic  tumour,  which  does  not  always  present  the  usual 
ovoid  shape  of  the  uterus.  Similarly,  it  may  be  equally  difficult 
or  impossible  to  reach  the  presenting  part  by  vaginal  examination. 
The  diagnosis  has  then  to  be  made  between  a  pregnant  uterus,  a 
cystic  tumour  of  the  ovary  or  of  the  uterus,  and  ascites.  If  the 
condition  present  is  uncomplicated,  the  diagnosis  is  usually  easy. 
In  a  case  of  intra-uterine  pregnancy,  there  is  a  cystic  tumour, 
corresponding  in  size  and  position  to  the  uterus,  the  subject  of 
alternate  contraction  and  relaxation,  and  apparently  continuous 
with  the  vaginal  portion  of  the  cervix.  It  may  be  possible  to 
detect  foetal  parts  and  to  hear  the  foetal  heart,  but  in  cases 
of  considerable  accumulation  of  fluid  it  will  be  impossible  to 
do  so.  In  the  case  of  an  ovarian  tumour,  we  get  a  history  of 
slower  growth,  and,  on  bi-manual  examination,  it  is  possible  to 
differentiate  between  the  tumour  and  the  uterus.  In  a  fibro- 
cystic tumour  of  the  uterus,  the  history  is  also  different,  and  the 
characteristic  signs  of  pregnancy  are  wanting.  In  ascites,  the 
fluid  changes  its  position  on  moving  the  patient,  the  dulness  on 
percussion  over  the  abdomen  extends  into  the  flanks,  and  a  wave 
of  fluctuation  can  usually  be  obtained.  Whenever  any  of  these 
conditions  complicate  a  case  of  hydramnios,  the  difficulty  of 
making  a  diagnosis  is  very  much  increased,  and  may  sometimes 


THE  TREATMENT  OF  HYDRAMNIOS  509 

only  be  made  by  waiting  until  the  onset  of  labour  clears  up  the 
nature  of  the  case. 

Once  it  has  been  determined  that  the  tumour  is  formed  by 
a  pregnant  uterus  alone,  the  diagnosis  of  the  cause  of  its  unusual 
size  is  not  difficult.  There  are  four  conditions  which  make  a 
pregnant  uterus  larger  than  normal,  and  these  are  multiple 
pregnancy,  vesicular  mole,  concealed  haemorrhage,  and  hydram- 
nios.  In  multiple  pregnancy,  the  foetal  parts  can  be  readily 
palpated,  and  the  increase  in  size  of  the  uterus  in  proportion  to 
the  period  of  pregnancy  is  not  very  marked.  One  or  more  foetal 
hearts  can  also  be  heard.  In  vesicular  mole,  there  is  a  history 
of  repeated  attacks  of  a  watery  blood-stained  discharge,  and  the 
uterus  is,  as  a  rule,  softer  and  more  boggy  in  consistency  than  in 
hydramnios.  In  concealed  accidental  haemorrhage,  there  is  a 
history  of  the  sudden  onset  of  the  haemorrhage  and  the  usual 
symptoms  of  haemorrhage.  The  diagnosis  of  hydramnios  is  thus 
arrived  at  by  a  process  of  exclusion. 

Treatment. — The  treatment  of  hydramnios  is  straightforward 
and  obvious.  During  pregnancy,  there  is  no  reason  to  interfere 
unless  the  symptoms  become  acute,  when  it  may  be  necessary 
to  induce  premature  labour.  This  is  best  done  by  puncturing 
the  membranes  and  allowing  the  liquor  amnii  to  drain  away 
gently,  as  by  this  means  any  acute  pressure  symptoms  are  imme- 
diately relieved,  and  labour  is  at  the  same  time  brought  on.  If, 
however,  the  symptoms  are  not  very  severe,  it  is  sufficient  to 
recommend  the  patient  to  refrain  from  an  undue  amount  of 
exercise  and  from  occupations  which  necessitate  standing  or 
walking,  to  wear  an  abdominal  belt,  to  regulate  the  bowels, 
and  to  watch  the  action  of  the  kidneys  with  a  view  to  ascertaining 
that  a  sufficient  quantity  of  urine  is  passed.  Some  authorities 
— notably  Pinard — advise  the  routine  administration  of  mercury 
and  iodide  of  potassium  in  these  cases,  in  consequence  of  the 
frequency  with  which  hydramnios  is  associated  with  syphilis. 
Whether  this  course  is  adopted  or  not,  a  history  of  syphilis  should 
always  be  sought  for,  and,  if  there  is  any  reason  to  suspect  its 
presence,  antisyphilitic  treatment  must  be  adopted. 

When  labour  comes  on,  we  must  endeavour  to  prevent  prema- 
ture rupture  of  the  membranes  and  the  sudden  escape  of  the 
liquor  amnii.  With  these  objects,  the  patient  is  kept  in  bed 
from  the  commencement  of  the  pains,  and  any  attempts  at 
straining  or  bearing-down  forbidden.  As  soon  as  the  os  is  half 
dilated,  it  is  advisable  to  rupture  the  membranes  artificially,  and 
to  allow  the  liquor  amnii  to  drain  away  slowly.  To  do  this,  the 
fingers  are  introduced  into  the  vagina  and  passed  upwards  a  little 
way  inside  the  uterine  orifice.  Then,  by  means  of  a  sterilised 
stilette  or  knitting-needle,  the  membranes  are  punctured  as  high 
up  as  can  be  reached  under  the  guidance  of  the  finger.  The 
fingers  must  be  kept  in  the  uterine  orifice  while  the  liquor  amnii 
is  escaping,  as  by  this  means  its  too  rapid  escape  is  prevented. 


5io  THE  PATHOLOGY  OF  PREGNANCY 

As  soon  as  it  has  all  escaped,  the  nature  of  the  presenting  part 
is  ascertained.  If  the  latter  is  normal,  there  is  no  further  reason 
to  interfere,  but,  if  a  malpresentation  is  present,  it  must  be 
corrected. 

If  the  contractions  of  the  uterus  are  too  feeble  to  expel  the 
foetus,  it  may  be  necessary  to  apply  the  forceps.  In  all  cases 
of  hydramnios,  the  necessary  means  of  treating  post-partum 
haemorrhage,  should  it  occur,  must  be  at  hand. 

Prognosis. — The  maternal  prognosis  in  hydramnios  is  not  serious 
if  the  case  is  under  surveillance  from  the  onset  of  the  condition, 
as,  if  the  symptoms  became  at  any  time  so  severe  as  to  threaten 
life,  labour  can  be  immediately  induced.  In  cases  of  considerable 
accumulation  of  fluid,  in  which  the  patient  has  neglected  to 
obtain  advice,  death  may  result  from  debility  dependent  on  the 
non-assimilation  of  sufficient  nourishment,  from  pulmonary  disease, 
from  cardiac  failure,  or  from  suppression  of  urine.  The  foetal 
prognosis  is  unfavourable,  both  in  consequence  of  the  patho- 
logical conditions  which  are  so  frequently  associated  with  hydram- 
nios, and  of  the  complications  which  may  arise  during  labour. 
According  to  Winckel,  only  one-third  of  the  infants  survive. 


OLIGO-HYDRAMNIOS 

By  the  term  '  oligo-hydramnios '  is  meant  the  absence  or 
insufficiency  of  liquor  amnii.  In  some  cases,  the  entire  amount 
of  liquor  amnii  may  be  only  one  or  two  drachms.  It  is  a  rare 
condition. 

Pathology. — It  is  as  difficult  to  determine  the  exact  pathology 
of  oligo-hydramnios  as  that  of  hydramnios.  All  that  can  be  said 
is  that  the  condition  is  associated  with  much  the  same  foetal 
diseases  and  abnormalities  as  is  hydramnios  (Ballantyne*),  and 
that  the  only  malformation  which  would  seem  to  be  more  common 
in  this  condition  than  in  hydramnios  is  ankylosis  of  the  foetal 
joints.  This  may  perhaps  be  accounted  for  by  the  diminished 
power  of  movement  on  the  part  of  the  foetus  owing  to  the  absence 
of  liquor  amnii,  and  so  must  be  considered  as  a  consequence  and 
not  a  cause  of  that  absence.  The  condition  of  the  foetal  urinary 
apparatus  does  not  bear  any  fixed  relation  to  either  hydramnios 
or  oligo-hydramnios,  inasmuch  as  both  these  conditions  have 
been  found  in  association  with  absence  of  the  kidneys,  and  with 
cystic  kidneys  the  result  of  urinary  obstruction.  From  this,  it 
would  appear  as  if  the  amount  of  urine  excreted  had  little  or 
nothing  to  say  to  the  amount  of  liquor  amnii.  This  view  is 
supported  by  the  results  of  the  experimental  administration 
of  phloridizin.  This  drug,  when  administered  to  the  mother,  is 
followed  by  the  secretion  of  sugar  by  the  maternal  and  foetal 
kidneys.     Investigations  of  thirty-four  pregnant  women  and  four 

*  Op.  cit. 


OLIGO-HYDR  AMNIOS 


S" 


animals  failed,  however,  to  determine  the  presence  of  sugar  in 
the  liquor  amnii  after  the  administration  of  the  drug,  and,  con- 
sequently, apparently  proved  that  the  fcetus  had  not  passed 
urine  after  its  administration  (Schaller).  Various  pathological 
changes  in  the  placenta  and  membranes  have  also  been  found 
in  association  with  oligo-hydramnios  ;  they  are,  however,  very 
similar  to  those  which  have  been  already  described  as  sometimes 
present  in  hydramnios. 

Symptoms. — The  symptoms,  if  any,  to  which  this  condition 
gives  rise  during  pregnancy  are  too  slight  to  be  noticeable. 
Subsequently,  labour  may  be  tedious  in  consequence  of  the  loss 


Fig.  268. — Ovum,  showing  Amniotic  Adhesions. 

a,  Adhesion;  b,  meningocele. 

(From  a  preparation  in  the  School  of  Physic,  Trinity  College,  Dublin. 


of  the  dilating  effect  of  the  bag  of  waters.  The  most  serious 
consequence  of  oligo-hydramnios  is,  however,  its  effect  upon  the 
membranes.  In  consequence  of  the  insufficiency  of  liquor  amnii, 
the  amniotic  sac  collapses,  and  the  walls  come  into  contact  with 
one  another.  Adhesions  then  form  at  the  points  of  contact,  and, 
as  the  fcetus  increases  in  size,  these  adhesions  are  drawn  out  into 
bands,  which  may  in  turn  become  wrapped  round  the  foetal 
limbs,  and,  by  tightening  on  the  latter,  cause  their  strangulation 
or  actual  amputation.  In  this  manner,  intra-uterine  amputations 
are  caused. 

Diagnosis. — -The  condition  cannot  be  diagnosed  until  the  mem- 
branes rupture,  and  the  liquor  amnii  is  found  to  be  insufficient  or 
practically  absent.     In  the  case   of  a  thin  patient,  perhaps,  the 


512 


THE  PATHOLOGY  OF  PREGNANCY 


existence  of  the  condition  may  be  suspected  by  noting  the 
unusually  distinct  manner  in  which  the  foetal  parts  can  be  felt, 
and  the  irregular  shape  of  the  uterus  during  a  contraction. 

Treatment. — There  is  no  treatment  applicable  to  this  condition, 
as  the  complications  to  which  it  gives  rise  cannot  be  prevented. 

Prognosis. — The  maternal  prognosis  is  not  materially  affected 
by  the  existence  of  oligo-hydramnios.  The  fcetal  prognosis  is, 
however,  more  serious,  as  will  be  readily  understood.  The 
absence  of  liquor  amnii  renders  the  foetus  more  liable  to  injury 
from  blows  or  pressure  on  the  abdomen  of  the  mother,  and  also 

_    mm 


w~*m 


'fcP;  •>> 


fill    i  ift 


Fig.  269. — Normal  (A)  and   Syphilitic  (B)  Chorionic  Villi  teased  out 
in  Salt  Solution,  and  Slightly  Magnified.     (Williams,) 

renders  the  placental  circulation  liable  to  interference,  while,  if 
amniotic  adhesions  form,  they  may  result  in  the  death  or  crippling 
of  the  foetus. 


SYPHILIS  OF  THE  OVUM 


The  Membranes  and  Placenta. — From  the  investigations  of 
Fraenkel,  of  Breslau,*  it  appears  that  the  chorion  is  the  chief  seat 
of  disease  in  the  ovum.  The  villi  are  invaded  by  a  dense  growth 
of    round   or   spindle    cells,    which    gradually   encroach   on   and 

*  Archiv  fur  Gynakol.,  vol.  v.,  pp.  1-54,  1873. 


SYPHILIS  OF  THE  MEMBRANES  AND  PLACENTA 


513 


cause  the  disappearance  of  the  vascular  loops,  and  ultimately  end 
in  a  process  of  fatty .  degeneration.  The  villi  so  affected  are 
readily  isolated  from  their  surroundings  ;  they  are  swollen,  opaque, 
and  rather  bulbous  at  their  extremities.  This  condition  may  be 
found  in  localised  areas  scattered  through  the  chorion,  or  it  or 
the  placenta  may  be  uniformly  affected. 

The  changes  met  with  in  the  placenta  of  syphilis  are,  as  a 
rule,  fairly  constant.  They  are  not,  however,  invariably  present, 
nor,  according  to  Ballantyne,*  absolutely  characteristic,  though 
they  are  usually  sufficiently  marked  to  draw  attention  to  the 
existence    of    some    pathological    condition,    and    to    the    prob- 


Fig.  270. — Normal  Full-term  Placenta,      x  50.     (Williams.] 


ability  of  that  condition  being  syphilis.  The  placenta  is  usually 
considerably  larger  than  normal,  and  is  of  a  pale-red  colour  inter- 
spersed with  yellowish  patches.  It  is  sometimes  soft  and  even 
friable.  Its  increase  in  weight  in  proportion  to  the  weight  of  the 
foetus  is  especially  marked  in  cases  in  which  the  foetus  is  born 
dead,  and  in  such  cases  its  weight  is  to  that  of  the  foetus  as  one  is 
to  four,  instead  of  the  normal  proportion  of  one  to  six.t  This 
increase  is  also  present  in  the  case  of  a  foetus  which  is  born  alive, 
though  it  is  not  then  so  marked.  J     The  most  characteristic  histo- 

*  Op.  cit.,  p.  230. 

t  C.  Ruge,  Zeitschr.  f.  Geburt.  it.  Gyntik.,  vol.  i.,  p  57,  1877. 

£  Correa  Diaz,  These  de  Paris,  1891. 

33 


514 


THE  PATHOLOGY  OF  PREGNANCY 


logical  alterations  consist  in  an  end-arteritis  and  peri-arteritis  of 
the  vessels,  in  cirrhotic  changes  in  the  connective  tissue  core, 
and  in  proliferation  of  the  epithelial  covering  of  the  villi,  some- 
times of  thickening  of  the  chorion,  and  of  arteritis  of  the  vessels 
of,  and  minute  gummata  in,  the  decidua  serotina  (Schwab*). 
The  quantity  of  blood  circulating  in  the  foetal  part  of  the  placenta 
is  diminished,  and  here  and  there  haemorrhages  are  met  with  in  the 
maternal  portion.  "The  so-called  gummata  of  the  placenta  are 
probably  hemorrhagic  in  their  origin,  or  are  due  to  fibrous  patches 
which  have  become  more  or  less  caseous ;    possibly,   however, 


true  gummata  may  in  exceptional  circumstances  be  met  with  " 
(Ballantyne).  The  macroscopical  structures,  which  used  to  be 
described  as  one  of  the  signs  of  placental  syphilis,  are  in  all  prob- 
ability nodules  of  fatty  degeneration  and  white  infarctions,  neither 
of  which  possess  any  relation  to  syphilitic  infection.  The  older 
notion  that  the  foetal  portion  of  the  placenta  was  alone  affected  in 
cases  in  which  the  infection  came  from  the  father — the  mother 
remaining  apparently  healthy,  and  the  maternal  portion  in  cases 
in  which  the  infection  came  from  the  mother  alone  is  no  longer 
accepted  as  probable. 

The  Cord. — Syphilitic  lesions  of  the  cord  are  not  infrequently 
met   with.     They    consist    most   frequently    in    endarteritis   and 

*  '  De  la  Syphilis  du  Placenta,'  These  de  Paris,  1896. 


SYPHILIS  OF  THE  FCETUS  515 

periarteritis  and  in  similar  lesions  of  the  veins,  leading  to  thicken- 
ing of  their  walls  and  a  varying  degree  of  obstruction  of  their 
lumen.  More  rarely,  complete  or  partial  absence  of  the  Whar- 
tonian  jelly  has  been  noticed — a  condition  which  may  bring  about 
mutual  disassociation  of  the  funic  vessels. 

The  Liquor  Amnii. — The  liquor  amnii  is  frequently  increased 
in  amount,  probably  from  a  rise  of  pressure  in  the  umbilical  vein 
from  lesions  in  the  placenta,  in  the  cord  itself,  or  in  the  fcetal 
liver.  Little  or  nothing  is  known  of  the  changes  in  the  quality 
of  the  fluid. 

The  Foetus. — There  are  two  different  classes  of  consequences 
for  the  foetus  as  pointed  out  by  Fournier  in  1898.  First,  special 
manifestations  of  the  disease  both  in  the  body  generally  and 
in  the  various  organs.  Secondly,  various  pathological  but  non- 
syphilitic  conditions,  or  dystrophies,  which  are  of  the  nature  of 
imperfections  or  arrests  of  development. 

The  special  manifestations  of  disease  may  appear  at  or  soon 
after  birth.  The  most  characteristic  is  an  eruption  of  pemphigus- 
like bullae,  or  in  their  early  stage  of  circular  copper-coloured 
patches.  The  bullae  contain  at  first  blood-stained  and  later 
purulent  fluid,  and  when  they  rupture  leave  irregular  and  super- 
ficial ulcers  often  covered  by  a  dark  crust.  These  bullae  and 
ulcers  are  numerous  and  of  various  sizes,  some  very  large  ;  they 
are  well  seen  about  the  genitals,  but  particularly — and  this  is 
characteristic  of  syphilis — upon  the  palms  and  soles.  The  body 
is  small  and  emaciated,  the  skin  wrinkled,  due  to  the  absence 
of  subcutaneous  fat,  and  the  general  appearance  of  the  infant  is 
senile. 

Death  of  the  foetus  is  very  common.  Hecker*  made  a 
thorough  examination  of  sixty-two  still-born  children,  and  found 
thirty-three  (53  per  cent.)  syphilitic  and  six  (9*7  per  cent.)  doubtful. 
Fifteen  out  of  the  thirty-three  had  to  be  examined  histologically 
before  the  diagnosis  could  be  made  certain.  Death  may  occur 
at  any  period  of  intra-uterine  life,  or  the  child  may  be  born 
alive  in  so  diseased  a  condition  as  to  entail  its  death  either  at  a 
very  early  or  a  later  period  of  infancy.  Even  if  death  does  not 
occur,  the  condition  of  disease  in  which  the  infant  is  born,  though 
permitting  life,  may  leave  it  in  such  a  condition  of  deformity  or 
ill  health  that  early  death  would  have  been  preferable. 

The  foetus  when  expelled  dead  is  usually  in  a  '  macerated  ' 
condition,  the  cuticle  peeling  off  in  large  flakes.  The  liquor 
amnii  is  of  a  dark-brown  colour.  These  appearances  are  not 
peculiar  to  syphilis,  as  is  sometimes  supposed,  they  are  found  in 
many  other  conditions  where  the  foetus  dies  and  is  retained  in 
utero  for  a  considerable  time.  The  foetus  is  often  spoken  of  as 
decomposed,  but  this  is  not  correct  unless  air  has  gained  access 
to  the  foetus,  carrying  with  it  putrefactive  bacteria. 

In  general,  the   pathological    changes   found    in    the  different 
*  Deutsch.  Med.  Woch,,  November  6  and  13,  1902. 

33—2 


516  THE  PATHOLOGY  OF  PREGNANCY 

organs  consist  in  diffuse  inflammatory  processes  invading  the 
interstitial  tissues  from  the  walls  of  the  smallest  vessels.  Micro- 
scopically, we  find  a  very  marked  small  round- celled  infiltration 
of  the  vessel  walls  and  neighbouring  connective  tissue  ;  and  this 
infiltration  is  accountable  for  the  increased  size  and  greater  firm- 
ness which  form  the  chief  macroscopic  evidences  of  congenital 
syphilis.  In  the  case  of  some  organs  specially  liable  to  attack, 
there  results  a  considerable  hyperplasia  of  fixed  cell  elements. 
Except,  however,  for  one  accustomed  to  the  normal  character- 
istics of  foetal  organs,  the  macroscopic  alterations  are  not  clearly 
marked,  and  it  must  be  on  microscopic  examination  that  a  certain 
diagnosis  rests. 

Of  late  years,  much  importance  has  come  to  be  attached  to  a 
special  form  of^osteo-chondritis,  as  affording  the  most  constant,  as 
well  as  probably  the  earliest,  evidence  of  syphilis.  This  is  an 
inflammatory  process,  which  affects  long  bones  and  ribs  at  the 
junction  of  the  diaphysis  and  epiphysis.  At  term,  the  line  of  junc- 
tion is  normally  0*5  mm.  broad,  while  in  syphilitic  osteo-chondritis 
it  is  2  to  3  mm.  broad,  and  sends  out  irregular  processes  into  the 
cartilage  and  more  markedly  into  the  diaphysis.  It  is  further 
characterised  by  its  intense  yellow  colour.  These  changes  may, 
before  or  after  birth,  progress  to  epiphysary  separation.  They 
can  be  readily  studied  on  a  longitudinal  section  through  epiphysis 
and  diaphysis  of  the  lower  end  of  the  femur.  This  is  the  prac- 
tical post-mortem  macroscopic  test  which  is  uniformly  adopted  in 
Germany.     Its  finer  microscopic  details  do  not  concern  us  here. 

Next  in  importance  come  the  changes  in  the  liver.  They 
appear  about  the  16th  week,  and  are  never  wanting  (Hochsinger) 
in  the  syphilitic  still-born.  The  liver  is  larger  and  firmer  than 
normal,  with  rounded  borders  and  increased  weight.  These  signs 
apply  mostly  to  children  born  alive  or  but  recently  dead,  and  where 
maceration  has  occurred  the  liver  may  be  flaccid  or  soft.  On 
section,  the  liver  substance  may  appear  more  translucent  than  is 
usual,  with  a  '  flinty  '  appearance  and  loss  of  lobular  demarcation, 
or  a  number  of  miliary  gummata  can  be  seen  through  the  trans- 
parent serous  covering,  scattered  over  the  surface,  and  giving  the 
semolina  grain  appearance  noted  by  Virchow.  Large  gummata 
are  quite  exceptional.  The  most  constant  of  all  appearances  is 
the  histological  one  of  a  diffuse  small-celled  infiltration,  having 
the  smaller  vessels  as  a  starting-point,  and  spreading  out  so 
extensively  over  the  entire  liver  as  on  first  glance  largely  to 
conceal  the  liver  cells  themselves. 

In  congenital  syphilis,  enlargement  of  the  spleen  is  constant. 
In  healthy  children  at  term,  this  organ  weighs  approximately 
ten  grams  ;  in  congenital  syphilis,  it  may  weigh  from  two  to 
four  times  as  much,  and  this  enlargement  is  probably  related 
rather  to  the  extreme  anaemia  that  is  present  in  such  cases  than 
to  a  specific  cause. 

The  kidney  changes  have  been  particularly  studied  by  Hoch- 


SYPHILIS  OF  THE  FCETUS  517 

singer,  who  describes  a  diffusely-spread  proliferation  of  inter- 
tubular  connective  tissue,  as  also  occasional  glomerulo-nephritis. 
Nephritis  is  certainly  frequent  in  such  cases,  and  fcetal  urine  has 
been  found  on  examination  to  contain  albumen  and  fatty  casts. 
The  lungs  frequently  show  well-marked  changes,  of  which  the 
chief  are  a  diffuse  gelatinous  infiltration,  whitish  solid  patches 
— pneumonia  alba  syphilitica — in  which  groups  of  air  vesicles  are 
filled  with  epithelial  cells  undergoing  fatty  degeneration,  and 
interstitial  fibroid  pneumonia. 

With  the  manifestations  of  non-syphilitic  nature — '  stigmates 
dystvophiques  de  V he vedito -syphilis  '  (Fournier) — we  have  little  to  do 
in  this  book,  and  must  confine  ourselves  to  mentioning  only  the 
principal.     Fournier  divides  them  into  the  following  groups  : — 

(1)  General  dystrophies,  such  as  the  simian  or  senile  physiog- 
nomy. 

(2)  Partial  dystrophies,  such  as  anencephalus,  meningocele, 
harelip,  clubfoot,  ectopia  vesicae,  ichthyosis,  and  many  others. 

(3)  Dystrophies  of  intellectual  development— viz.,  retarded  or 
arrested  development. 

(4)  Dystrophies  of  predisposition — e.g.,  hemorrhagic  diathesis, 
tubercle,  nervous  diseases. 

Fournier  also  mentions  many  other  conditions  which  he  does 
not  consider  as  dystrophies  peculiar  to  syphilis,  but  which  are  met 
with  in  sufficient  frequency  in  syphilitic  cases  to  shew  that  they 
are  not  mere  coincidences,  but  a  real  relation  of  cause  and  effect. 

These  effects  of  syphilis  on  the  fcetus  and  foetal  appendages 
are  greatly  modified  by  the  following  circumstances  : — 

(1)  The  time  in  relation  to  pregnancy  at  which  infection  takes 
place.  Fournier's  tables  show  that,  when  infection  occurred  before 
conception,  the  fcetal  mortality  is  65  per  cent,  and  the  morbidity 
(i.e.,  evidence  of  disease)  70  per  cent. ;  when  conception  and 
infection  occur  simultaneously,  the  mortality  is  75  per  cent,  and 
the  morbidity  91  per  cent. ;  while,  when  the  infection  has  taken 
place-  after  conception,  the  mortality  is  39  per  cent,  and  the 
morbidity  72  per  cent. 

(2)  The  source  of  the  infection.  Fournier's  tables  show  that, 
when  the  father  alone  is  responsible,  the  mortality  is  28  per  cent, 
and  the  morbidity  37  per  cent. ;  where  the  mother  is  the  trans- 
mitter, 60  per  cent,  and  80  per  cent.  ;  and  where  both  parents 
transmit,  68*5  per  cent,  and  92  per  cent. 

(3)  The  age  of  the  disease  in  the  transmitter.  The  first  three 
years  of  infection  are  the  most  fatal  to  pregnancies,  and  the 
first  year,  including  the  period  of  secondary  manifestations,  is 
much  the  worst.  Of  ninety  women  who  became  pregnant  during 
the  year  following  their  infection,  only  two  gave  birth  to  children 
who  survived.  As  the  disease  becomes  older,  the  danger  becomes 
less.  It  is  said  (Hutchinson)  that  the  liability  to  transmit  the 
infection  to  the  ovum  ends  in  two  years  in  the  case  of  the  father, 
but   is    extended   in   the  case  of  the  mother    to   seven  or  eight 


5*8 


THE  PATHOLOGY  OF  PREGNANCY 


years,  while  exceptional  cases  have  been  recorded  in  which 
transmission  occurred  after  ten  or  fourteen  years.  We  doubt, 
however,  that  in  the  case  of  the  father  an  interval  of  two  years 
since  infection  is  sufficient  to  ensure  immunity.  Hutchinson  also 
thinks  that  in  the  case  of  the  woman  the  virus  may  be  stored 
up  in  the  ovaries  and  may  infect  the  germs  of  future  children. 

(4)  The  adoption  of  treatment.  This  no  doubt  profoundly 
modifies  the  course  of  events,  and  will  be  discussed  later  (v. 
Part  VI.,  Chapter  IV.,  sections  on  Maternal  Syphilis). 


ANOMALIES  AND  DISEASES  OF  THE  PLACENTA 

Anomalies  of  Position. — Under  normal  circumstances,  the 
placenta  is  situated  in  the  upper  uterine  segment,  and  on  either 
the  anterior  or  the  posterior  wall.  According  to  some  writers, 
it  is  situated  as  frequently  on  the  anterior  wall  as  on  the  posterior 
(Gusserow  and  Hennig*),  but  according  to  others  it  is  most 
frequently  situated  upon  the  posterior  wall.  Pinard  and  Varniert 
found  the  following  proportion  in  37  cases  which  they  examined  : — 


Situation. 


Posterior  wall. 
Anterior  wall. 
Fundus. 

Right  lateral  wall. 
On  both  anterior  and  posterior 
wall  (triplets). 


The  only  situation  of  the  placenta  which  can  be  regarded  as 
abnormal  is  that  in  which  any  portion  of  it  extends  into  that  part 
of  the  uterus  from  which  the  lower  uterine  segment  is  formed. 
According  to  Barnes,];  the  placenta  must  be  considered  to  be 
abnormally  situated  if  it  approaches  within  three  inches  of  the 
undilated  internal  os.  This  distance  is  perhaps  a  little  too  great. 
A  placenta  which  is  inserted  in  the  lower  uterine  segment  is 
termed  placenta  prczvia,  in  consequence  of  its  position  in  front  of 
the  presenting  part,  and  as  a  rule  gives  rise  to  serious  ante- 
partum haemorrhage.  This  will  be  again  referred  to  at  length  in 
discussing  the  haemorrhage  of  pregnancy,  and,  consequently,  need 
not  be  dealt  with  here. 

Anomalies  of  Size  and  Shape. — A  placenta  membranacea  is  the 
term  applied  to  a  large  and  thin  placenta,  the  result  of  persist- 
ence of  the  chorionic  villi  over  a  large  portion  of,  or  even  over 

*  Monatss.  /.  Geburts.,  vol.  xxvii.,  p.  90,  1866,  and  '  Studien  uber  den  Bau  der 
Placenta,'  Leipzig,  1872. 

t  '  Etude  d'Anatomie  Obstetricale  Normale  et  Pathologique,'  p.  2,  Paris, 
1892. 

I  '  Obstetric  Operations,'  third  edition,  p.  494. 


ANOMALIES  OF  THE  PLACENTA  519 

the  entire,  ovum.  The  practical  importance  of  such  a  condition 
is  that,  during  the  third  stage,  detachment  is  difficult,  owing  to 
the  thin  placenta  crumpling  up  inside  the  contracting  uterus. 

A  placenta  succenturiata  is  the  term  applied  to  the  condition  in 
which  the  placenta,  instead  of  being  a  single  organ,  is  divided  into 
two  or  more  lobes  {v.  Fig.  272).  These  lobes  are  connected  with 
one  another  by  branches  of  the  umbilical  vessels,  which  run 
across  the  membranes.  If  there  are  two  almost  equal  lobes,  the 
condition  is  known  as  a  bi-lobed  placenta.  A  placenta  succen- 
turiata  is  of  considerable  practical  importance  on  account  of  the 
danger  of  one  of  the   smaller  portions  being  left    behind   after 


P* 


P 


-"■ 


m 


Fig.  272. — A  Placenta  Succenturiata. 
P,  Main  placenta  ;  P',  secondary  detached  lobe. 

labour.  Fortunately,  in  the  majority  of  cases,  such  an  occurrence 
will  give  rise  to  immediate  post-partum  haemorrhage,  and  in  the 
process  of  checking  the  latter,  the  retained  piece  of  placenta  will 
be  found  and  removed.  If,  however,  there  is  no  immediate 
haemorrhage,  and  the  retained  portion  is  undiscovered,  secondary 
post-partum  haemorrhage  may  occur,  or  the  retained  portion  may 
become  putrid  and  give  rise  to  sapraemia.  It  is,  then,  most  im- 
portant to  recognise  the  existence  of  a  placenta  succenturiata,  and 
it  is  always  possible  to  do  so  if  the  necessary  precautions  are  taken 
to  examine  the  placenta  and  membranes  after  their  expulsion. 
Where  a  placenta  succenturiata  has  been  left  behind,  a  gap  will 
be  found  in  the  membranes  corresponding  to  the  retained  portion 


520  THE  PATHOLOGY  OF  PREGNANCY 

of  placenta,  and  branches  of  the  umbilical  vessels  will  be  found 
running  to  the  edge  of  the  gap.  In  such  a  case,  the  uterus  must 
always  be  explored  with  the  fingers  and  the  retained  fragment 
removed. 

A  placenta  marginata  is  the  term  applied  to  a  placenta  in  which 
the  membranes  instead  of  being  attached  round  the  edge  are 
attached  some  little  way  inside  the  edge,  in  such  a  manner  that 
a  margin  of  placenta  projects  all  round  outside  their  attachment. 
According  to  Kiistner  this  condition  is  due  to  an  unequal  rate  of 
growth  of  the  uterus  and  the  placenta  respectively,  with  the 
result  that  the  maternal  portion  of  the  placenta  becomes  larger 
than  the  foetal  portion.  Klein,*  on  the  other  hand",  considers  that 
the  condition  is  due  to  a  marginal  thickening  of  the  decidua 
reflexa,  as  a  result  of  some  inflammatory  process  such  as  decidual 


Fig.  273. — A  'Battledore'  Placenta. 

endometritis.  A  marginal  placenta  interferes  with  the  develop- 
ment of  the  foetus,  as  is  to  be  expected  in  view  of  the  fact  that 
the  area  of  interchange  between  the  foetal  and  maternal  blood  is 
lessened.  In  a  series  of  forty  cases,  collected  by  R.  Martin,! 
45  per  cent,  of  the  infants  weighed  less  than  four  and  a  half 
pounds. 

A  battledore  placenta  is  a  placenta  in  which  the  insertion  of  the 
umbilical  cord  is  at  the  edge  instead  of  being  more  or  less  in  the 
centre  {v.  Fig.  273).  It  is  more  correctly  considered  to  be  an 
abnormality  of  the  cord  rather  than  of  the  placenta. 

Tumours. — Tumours— i.e.,  new  growths — of  the  placenta  are  of 
extremely  rare  occurrence.     Thirty-six  cases  have  been  collected 

*  '  Zur  Enstehung  der  Placenta  marginata,  in  die  menschlichen  Placenta,' 
Wiesbaden,  1890. 

t  Ribemont-Dessaignes  and  Lepage,  'Precis  d'Obstetrique,'  3rd  edit., 
p.  706. 


ANOMALIES  OF  THE  PLACENTA  521 

(Albert*),  but  it  is  probable  that  some  of  these  may  not  have 
been  new  growths.  These  cases  consisted  of  myxoma  fibrosum, 
14  ;  fibroma,  10  ;  angioma,  9  ;  sarcoma,  2  ;  hyperplasia  of  chori- 
onic villi,  1.  Myxoma  fibrosum  was  described  by  Virchow,  and 
is  the  commonest  tumour  met  with.  It  consists  of  solid  masses 
of  fibro-myxomatous  tissue,  occurring  either  as  a  single  tumour 
or  as  multiple  nodules  scattered  through  the  placenta.  It  is  in 
all  probability  identical  with  the  tumours  already  mentioned  in 
which  hyperplasia  of  the  chorionic  epithelium  is  associated  with 
hypertrophy  of  the  stroma  of  the  villus.  Chorio-epithelioma  is 
not  included  in  Albert's  list,  although  it  is  as  true  a  placental 
tumour  as  is  myxoma  fibrosum.  It  is  probable,  to  say  the  least, 
that  the  cases  recorded  as  sarcoma  were  instances  of  chorion- 
epithelioma  or  possibly  of  fibroma.  '  Hyperplasia  of  the  chorionic 
villi'  was  probably  a  stage  in  the  formation  of  vesicular  mole. 

Cysts.- — Two  forms  of  cysts  of  the  placenta  are  met  with,  both 
of  which  are  situated  on  the  foetal  surface.  The  commoner  form 
is  a  haemorrhagic  or  blood  cyst.  It  is  usually  situated  under  the 
chorion,  and  may  be  single  or  multiple.  It  is  probably  produced 
by  the  rupture  of  small  vessels,  and  contains  a  stratified  fibrinous 
lining  inside  which  is  a  little  blood-stained  serous  fluid  or  blood. 
The  second  form  of  cyst  is  found  in  the  substance  of  the  sub- 
amniotic  chorion  (Eden),  and  is  probably  produced  by  a  myxo- 
matous degeneration  of  the  chorionic  connective  tissue.  It  may 
occur  as  a  single  cyst  or  as  multiple  cysts.  The  cysts  are  usually 
about  the  size  of  a  pigeon's  egg,  and  contain  a  clear  viscid  fluid. 
They  do  not  interfere  with  the  functions  of  the  placenta. 

(Edema  of  the  Placenta. — CEdema  of  the  placenta  may, 
apparently,  occur  in  association  with  either  maternal  or  foetal 
oedema,  and  is  dependent  upon  similar  causes.  The  most 
frequent  of  these  causes — so  far  as  the  foetus  is  concerned — is 
some  defective  condition  of  the  heart  or  blood-vessels,  such  as 
foetal  endocarditis,  a  closed  foramen  ovale,  or  thrombosis  of  the 
umbilical  and  hypogastric  vessels.  An  cedematous  placenta  has 
also  been  met  with  in  cases  of  an  acardiac  foetus,  diaphragmatic 
hernia  with  presumed  compression  of  the  inferior  vena  cava, 
transposition  of  the  viscera,  and  various  pathological  conditions 
Of  the  liver.  The  placenta  sometimes  reaches  a  very  great  size 
in  these  cases,  and,  according  to  Ballantyne,i  may  attain  a  weight 
of  from  three  to  six  pounds.  It  is  soft  in  consistence  and  very 
anaemic.  The  umbilical  cord  is  also  usually  thick  and  cedematous, 
and  sometimes  friable.  There  may  also  be  thickening  of  the 
chorion  and  amnion. 

As  a  rule,  the  foetus  is  born  dead,  either  in  consequence  of 
interference  with  the  placental  circulation,  or  in  consequence  of 
the  pathological  condition  which  has  caused  the  placental  oedema. 
Cases,  however,  have  been  recorded  in  which  the  foetus  was  born 

*  '  Ueber  Angiome  der  Placenta,'  Archiv  f.  Gyn.,  1898,  vol.  lvi.,  pp.  144-159. 
I  Op.  cit..  p.  293. 


522  THE  PATHOLOGY  OF  PREGNANCY 

alive.  As  antenatal  diagnosis  of  the  condition  or  of  its  cause  is 
impossible,  there  is  no  treatment. 

Tuberculosis. — Tuberculosis  of  the  placenta  is  a  very  rare 
condition,  but  cases  have  been  recorded  and  definitely  proved 
(Schmorl*).  As  is  to  be  expected  they  were  met  with  in  women 
suffering  from  pulmonary  or  acute  miliary  tuberculosis.  The 
tubercular  lesions  present  much  the  same  characteristics  as  in 
other  places.  The  nodules  are  found  in  the  substance  of  the 
cotyledons  more  often  than  upon  the  surface,  and  are  more 
abundant  in  the  marginal  than  in  the  central  parts  (Edenf).  It 
is  interesting  to  note  the  condition  of  the  foetus  in  cases  of  pla- 
cental tuberculosis.  Kuss,  \  who  has  investigated  the  subject  very 
fully,  considers  that  even  in  cases  in  which  the  infection  reaches 
the  placenta,  the  latter  structure  has  power  to  prevent  the  further 
extension  of  the  infection.  This  conclusion,  however,  cannot  be 
taken  as  law,  inasmuch  as  cases  of  antenatal  foetal  tuberculosis 
have  been  recorded  (Hauser,  Lebmann§).  There  can  be  no  doubt 
that  the  placenta  offers  a  considerable  resistance  to  the  passage  of 
bacteria,  but  inasmuch  as  other  -bacteria  pass  through  it  there 
seems  to  be  no  adequate  reason  why  tubercular  bacilli  should  not 
also  do  so.  The  only  other  route  by  which  the  infection  can 
reach  the  foetus  is  as  a  '  water-borne'  infection — i.e.,  through  the 
liquor  amnii,  and  this  route  though  possible  is  not  probable, 
as  it  means  that  bacteria  have  passed  through  the  membranes. 

Calcareous  Degeneration. — It  is  by  no  means  uncommon  to 
find  calcareous  plates,  scattered  here  and  there  on  the  maternal 
surface  of  the  placenta.  These  plates  can  usually  be  seen,  but 
sometimes  are  more  readily  discovered  by  passing  the  fingers 
over  the  surface,  when  they  are  felt  as  projecting  sharp  edges 
or  spikes.  In  some  cases,  almost  the  entire  face  of  the  placenta 
has  been  found  covered  with  a  thin  plate.  These  plates  are  due 
to  a  deposit  of  lime  salts  in  the  decidua  serotina,  and  do  not 
affect  the  foetal  portion  of  the  placenta.  Like  infarctions,  they 
are  probably  a  sign  of  '  senility '  of  the  placenta.  Their  presence 
has  no  prejudicial  effect  upon  the  foetus  ;  indeed,  according  to  one 
writer,  the  latter  is  larger  than  normal  (R.  Martin||). 

Placental  Infarction. — Infarction  of  the  placenta  is  a  condition 
of  relatively  common  occurrence.  The  infarctions  vary  consider- 
ably in  size  according  to  their  cause,  and  in  appearance  according 
to  their  age.  In  an  early  stage,  the  infarction  resembles  a  mass 
of  dark  clotted  blood,  and  as  the  colouring  matter  of  the  blood 
disappears,  the  infarction  becomes  successively  chocolate  coloured, 

*  'Die  Tuberkulose  der  menschlichen  Placenta,' etc.  Ziegler's  Beitrage, 
xvi.  313. 

j-  Encyc.  Medica.,  vol.  ix.,  p.  19. 

X  'De  l'Heredite  Parasitaire  de  la  Tuberculose  Humaine,'  Paris,  1898. 

§  '  Zur  Vererbung  der  Tuberkulose.'  Deutsche  Archiv  f.  Klin.  Med.,  1898, 
Ixi.  221. 

II  These  de  Paris,  1806. 


PLACENTAL  INFARCTION  523 

then  yellowish,  and  lastly,  of  a  grayish  white  colour.  Williams,* 
whose  work  on  this  subject  is  well  known,  summarises  his 
conclusions  as  follows  : — 

(1)  Infarcts,  measuring  at  least  one  centimetre  in  diameter, 
were  found  in  315  out  of  500  consecutive  placentae. 

(2)  Smaller  infarcts,  many  just  visible  to  the  naked  eye,  were 
observed  in  the  great  majority  of  placentae,  while  microscopical 
examination  revealed  early  stages  of  infarct  formation  in  every 
full-term  placenta. 

(3)  The  primary  cause  of  infarct  formation  in  the  great  majority 
of  cases  is  to  be  found  in  an  endarteritis  of  the  vessels  of  the 
chorionic  villi. 

(4)  The  primary  result  of  the  endarteritis  is  coagulation 
necrosis  of  the  portions  of  the  villi  just  beneath  the  syncytium, 
with  subsequent  formation  of  canalized  fibrin.  As  the  process 
becomes  more  marked  the  syncytium  also  degenerates  and 
becomes  converted  into  canalized  fibrin,  and  this  is  followed 
by  the  coagulation  of  blood  in  the  intervillous  spaces,  which 
results  in  the  matting  together  of  larger  or  smaller  groups  of 
villi  by  masses  of  fibrin.  Later,  the  entire  stroma  of  the  villi 
degenerates,  so  that  the  infarct  consists  entirely  of  a  net-work 
of  fibrin.  When  infarction  is  carried  to  a  marked  degree,  the 
placenta  is  converted  into  a  firm  yellowish  mass  containing  little 
blood. 

(5)  Moderate  degrees  of  infarct  formation  possess  no  patho- 
logical significance  and  exert  no  influence  upon  the  mother  or 
fcetus.  They  are  to  be  regarded  as  a  sign  of  senility  of  the 
placenta. 

(6)  Marked  infarct  formation  is  not  infrequently  observed,  and 
often  results  in  the  death  or  imperfect  development  of  the  fcetus. 
It  is  usually  associated  with  albuminuria  on  the  part  of  the 
mother. 

We  may  briefly  summarise  the  aetiology  of  infarction  in  a  few 
words.  The  primary  cause  of  the  infarction  is  to  be  found  in 
some  fcetal  condition,  while  the  deposit  of  fibrin  is  derived  from 
the  maternal  blood.  The  occurrence  of  small  infarctions  is  due 
to  age  changes  in  the  placenta.  The  cause  of  large  infarctions 
is,  in  the  great  majority  of  cases,  to  be  found  in  maternal  renal 
disease.  Cardiac  disease  and  syphilis  may  also  give  rise  to  their 
formation. 

The  effect  of  a  considerable  degree  of  infarction  upon  the  fcetus 
is  very  obvious.  In  the  great  majority  of  cases  the  latter  is  below 
the  normal  size  and  in  many  cases  is  born  dead.  This  is  only 
what  we  would  expect,  inasmuch  as  a  partial  limitation  of  the 
functionally  active  area  of  the  placenta  is  bound  to  result  in  a 
diminution  in  the  supply  of  nutriment  to  the  fcetus,  while  a  con- 
siderable lessening  will  probably  interfere  to  such  a  degree  as  to 
prevent  its  further  development. 

*  Amer.  Jour,  of  Obstetrics,  1900,  vol.  xli.,  pp.  775-801. 


524  THE  PATHOLOGY  OF  PREGNANCY 

Placenta  of  Renal  Disease. — The  characteristic  placenta  of  renal 
disease,  or  the  albuminuric  placenta,  as  it  is  sometimes  termed,  is, 
as  a  rule,  easily  recognisable.  Its  chief  characteristic  is  the  number 
of  infarcts  of  different  ages  which  are  scattered  through  it.  If 
the  number  of  infarctions  is  considerable,  the  placenta  appears 
atrophied  and  fibrous.  The  weight  of  the  placenta  is  also  below 
the  normal.  When  the  infarctions  are  of  recent  occurrence  they 
partake  more  of  the  nature  of  thrombosis  of  the  blood  in  the 
intervillous  spaces.  In  such  cases,  the  placenta  appears  to  be 
studded  over  with  numerous  globular  or  oval  areas  containing 
dark  red,  or  nearly  black,  coagulated  blood.  These  areas  project 
on  the  maternal  surface  of  the  placenta,  and  also  lie  more  deeply 
in  the  placental  structure.  To  such  a  placenta,  the  name 
'  placenta  truffe  '  has  been  given  by  Pinard. 

It  is  difficult  to  ascertain  what  proportion  of  cases  of  renal 
disease  are  associated  with  placental  infarction.  Many  cases  of 
renal  disease  escape  notice  altogether,  and  in  many  other  cases 
the  occurrence  of  albuminuria  may  have  been  coincident,  or 
almost  coincident,  with  the  onset  of  labour,  and  therefore  could 
not  cause  placental  lesions.  Martin*  in  a  number  of  cases  has 
found  placental  lesions  in  47  per  cent,  of  patients  who  suffered 
from  albuminuria  during  pregnancy.  It  is  also  difficult  to  ascer- 
tain the  particular  form  of  renal  disease  which  is  most  usually 
associated  with  placental  infarction,  but  it  is  obvious  that  all 
forms  are  not  equally  prone  to  give  rise  to  it.  The  kidney  of 
pregnancy  does  not  tend  to  do  so,  and  a  large  amount  of  albumin 
in  the  urine  is  not  necessarily  associated  with  a  marked  degree 
of  infarction  (Ribemont-Dessaignesf).  It  is  probable  that  the 
most  typical  cases  of  albuminuric  placenta  occur  in  chronic  inter- 
stitial renal  disease,  and  that  the  longer-standing  the  case  is,  the 
more  marked  the  placental  lesions  will  be. 


ANOMALIES  OF  THE  UMBILICAL  CORD 

Anomalies  of  Length. — The  average  length  of  the  cord  at  full 
term  is  about  22  inches,  but  considerable  variations  are  not  infre- 
quently met  with.  Neugebauer  met  with  a  case  in  which  the 
length  of  the  cord  was  67!  inches,  while,  on  the  other  hand, 
cases  have  been  recorded  in  which  the  cord  was  apparently  non- 
existent, so  close  was  the  connection  between  the  foetus  and  the 
placenta.  The  latter  condition  is  usually  associated  with  umbilical 
hernia.  In  practice,  every  cord  must  be  considered  too  short 
which  is  not  equal  to  the  greatest  distance  during  labour  between 
the  umbilicus  of  the  foetus  and  the  insertion  of  the  cord  into  the 
placenta.  If  it  is  not  of  this  length,  tension  of  the  cord  will  occur, 
and  the  expulsion  of  the  foetus  may  be  delayed,  rupture  of  the 
cord  may  occur,  or  the  placenta  may  be  forcibly  detached. 

*  These  de  Paris,  1896.  f  '  Precis  d'Obstetrique,'  p.  759. 


ANOMALIES  OF  THE  UMBILICAL  CORD  525 

The  excessive  length  of  the  cord  sometimes  results  in  its  coiling 
round  the  neck  or  body  of  the  fcetus,  or  in  the  formation  of  knots. 
The  coiling  of  the  cord  round  the  neck  is  a  very  common  occur- 
rence even  in  cases  in  which  the  cord  cannot  be  considered  to  be 
unduly  long,  and  even  in  some  cases  in  which  it  is  below  the 
average  length.  Churchill  met  with  fifty-two  cases  of  coiling  in 
190  deliveries.  In  none  of  these  did  the  cord  measure  less  than 
eighteen  inches  ;  when  the  cord  was  twice  round  the  neck  it  was 
at  least  twenty-four  inches,  and  when  three  times  round  at  least 
thirty-six  inches  in  length.  A  case,  however,  was  recorded  by 
another  writer,  in  which  a  cord  measuring  thirty-four  inches  was 
six  times  round  the  neck.*  Coiling  of  the  cord  round  the  fcetus  is 
of  no  importance  so  long  as  the  loops  do  not  become  unduly  tight, 
in  fact,  in  the  case  of  long  cords,  it  may  be  regarded  as  a  provision 


Fig.  274. — Coiling  of  the  Umbilical  Cord. 
k,  A  false  knot  on  the  cord. 

Note  the  manner  in  which  the  cord  is  twisted  several  times  round  the  limbs. 
(From  a  specimen.) 

of  Nature  to  prevent  their  presentation  and  prolapse.  If,  how- 
ever, the  coils  become  tightened  round  the  fcetus,  the  death  or 
deformity  of  the  latter  may  result  from  obstruction  of  the  circula- 
tion in  the  cord  or  compression  of  the  foetal  limbs  by  the  coils ; 
and,  in  consequence  of  the  shortening  of  the  uncoiled  portion  of 
the  cord,  difficulties  may  arise  during  labour  as  in  the  case  of  a 
cord  which  was  primarily  too  short. 

The  formation  of  knots  is  a  much  rarer  occurrence.  According 
to  Winckelf  two  conditions  are  necessary  for  their  formation  : — 
A  cord  which  in  length  exceeds  twice  the  distance  from  the 
umbilicus  to  the  vertex  ;  and  a  small  fcetus  or  a  large  quantity  of 
liquor  amnii,  in  order  to  ensure  the  mobility  of  the  former. 

It  is  probable  that  in  many  cases  the  knot  remains  open  until 
labour  commences,  when  the  tension  imparted  to  the  cord  by  the 

*  Neue  Zeitschrift,  vol.  xiii.,  p.  2.  t  Op.  cit.,  p.  352. 


526 


THE  PATHOLOGY  OF  PREGNANCY 


descent  of  the  foetus  closes  it.  When  the  knot  has  been  tightened 
during  pregnancy  distortion  of  the  cord  will  persist  even  after  it 
has  been  untied,  owing  to  the  effect  of  the  continued  pressure  on 
the  Whartonian  jelly,  while  if  it  has  only  formed  during  delivery 
it  can  be  easily  shaken  out.     It  is  of  course  possible  that  the  knot 


Fig.  275. — False  Knots  on  the  Cord. 

A,  Large  varix  of  umbilical  vein  ;  B,  spiral  twisting  of  an  umbilical 
artery.     (Bumm.) 


may  become  so  tightly  drawn  as  to  offer  a  partial  or  complete 
obstruction  to  the  funic  circulation.  This,  however,  very  rarely 
occurs.  False  knots,  due  to  twisting  or  dilation  of  the  vessels,  or 
accumulations  of  Whartonian  jelly,  are  of  fairly  common  occur- 
rence (v.  Fig.  275).  They  are  readily  distinguished  from  true 
knots. 


ANOMALIES  OF  THE  UMBILICAL  CORD  52 

Excessive  torsion  of  the  cord  may  also  be  found  in  some  cases. 
It  is  probably  due  to  the  same  predisposing  factors  which  favour 
the  occurrence  of  knots,  i.e.,  a  long  cord,  and  an  abnormal  degree 
of  foetal  mobility.  To  show  the  extent  to  which  torsion  may  be 
carried,  we  may  mention  a  case  recorded  by  Schauta,  in  which 
there  were  380  twists.  The  danger  of  torsion  is  that  it  may 
produce  kinking  and  obliteration  of  the  vessels. 

Anomalies  of  Development. — The  various  anomalies  of  develop- 
ment of  the  cord  are  not  of  any  great  practical  importance,  and 
are  never  recognised  until  the  birth  of  the  foetus.  They  do  not 
tend  to  interfere  with  labour,  though  possibly  in  some  cases  they 


Fig.  276. — Velamentous  Insertion  of  the  Cord. 

may  increase  the  risk  of  laceration  of  the  funic  vessels  during 
labour,  and  so  affect  the  foetal  prognosis.  The  various  anomalies 
which  are  met  with  are  briefly  as  follows  (Hyrtl*)  : — 

(1)  The  vessels  may  divide  at  a  distance  of  from  two  to  four 
inches  from  the  placenta  or  from  the  umbilicus  of  the  foetus. 

(2)  One  vein  and  one  artery  are  found  instead  of  the  normal 
arrangement  of  one  vein  and  two  arteries.  Two  veins  and  one 
artery  have  also  been  found,  and  three  arteries  and  one  vein. 

(3)  The  funis  runs  as  a  double  cord  from  the  umbilicus  to  the 
placenta,  the  vein  in  one  division,  the  two  arteries  in  another. 

(4)  In  twins  a  rare  occurrence   is  fusion  of  the  cords  into  a 

*  '  Die  Blutgefasse  der  msnschl.  Nachgeburt,'  Wien,  1870. 


528  THE  PATHOLOGY  OF  PREGNANCY 

single  cord  some  little  distance  from  the  placenta,  and  then 
separation  as  the  umbilicus  of  the  foetus  is  approached.  In  a 
recorded  case,  there  was  one  artery  and  one  vein  in  each  single 
cord,  while  in  the  common  cord  there  was  also  only  one  artery 
and  one  vein,  each  of  which  bifurcated  with  the  cord. 

Abnormal  Insertion  of  the  Cord. — In  some  cases  the  cord, 
instead  of  being  inserted  into  the  placenta,  is  inserted  into  the 
membranes,  and  splitting  up  at  the  point  of  insertion  into  its 
usual  branches,  these  run  along  in  the  membranes  for  some  little 
distance  before  they  reach  the  placenta.  To  this  condition,  the 
term  velamentous  insertion  of  the  cord  is  applied  (v.  Fig.  276). 
Winckel  found  this  anomaly  90  times  in  11,000  births,  or  0-82 
per  cent.  A  curious  fact,  which  he  mentions,  is  association  of 
this  condition  with  abnormal  presentation  of  the  foetus.  Shoulder 
presentation  was  ten  times  and  pelvic  presentation  four  times,  as 
frequent  as  in  other  cases.  Velamentous  insertion  of  the  cord 
may  prove  of  danger  to  the  life  of  the  fcetus,  especially  when  the 
portion  of  membranes  traversed  by  the  cord  forms  the  presenting 
bag  of  membranes,  as  during  the  rupture  of  the  latter  the  vessels 
of  the  cord  may  be  torn  across. 

It  is  possible  that  in  some  cases  the  existence  of  a  velamentous 
condition  may  be  recognised  before  the  rupture  of  the  membranes 
by  feeling  a  pulsating  artery  traversing  the  presenting  membranes. 
If  this  was  done,  the  best  course  to  pursue  would  be  to  puncture 
the  membranes  with  a  stylette  in  such  a  manner  as  to  avoid  the 
vessel,  and  then  to  deliver  the  fcetus  with  the  forceps  as  soon  as 
the  os  was  sufficiently  dilated  to  allow  this  to  be  done. 

A  marginal  insertion  of  the  cord  is  another  anomaly  which  is 
sometimes  met  with.  This  condition  is  also  spoken  of  as  a 
battledore  placenta,  and  is  of  little  or  no  practical  importance. 


CHAPTER  III 

PATHOLOGICAL  CONDITIONS  OF  THE  UTERUS,  THE 
VAGINA,  AND  ADNEXA 

Displacements  of  the  Uterus :  Backward  Displacements ;  Consequences, 
Restitution,  Abortion,  Incarceration,  Development  of  the  Anterior  Uterine 
Wall — Forward  Displacements  ;  Pathological  Anteflexion  ;  Pathological 
Anteversion — Downward  Displacements  ;  Prolapse  and  Procidentia  of 
the  Uterus  ;  Prolapse  of  the  Vaginal  Walls  ;  Hypertrophy  of  the  Cervix — 
Hernia  of  the  Pregnant  Uterus — Malformations  of  the  Uterus  and  Vagina 
— Inflammation  of  the  Vagina  and  Cervix — Tumours  of  the  Uterus  and 
Ovaries. 

The  various  pathological  conditions,  which  are  met  with  in  the 
uterus,  vagina,   and  adnexa   as  causes  of  complications  during 
pregnancy,  will  be  considered  under  four  heads:— 
I.  Displacements. 
II.   Hernia. 

III.  Congenital  malformations. 

IV.  Inflammation. 
V.  Tumours. 


DISPLACEMENTS  OF  THE  UTERUS 

The  various  displacements  of  the  uterus  affect  the  course  of 
pregnancy  according  as  they  interfere  with  the  mobility  of  that 
organ  or  cause  congestion  of  it,  and  displacements  which  do  not 
affect  the  uterus  in  either  of  these  ways  will  not  be  found  as 
pathological  factors  during  pregnancy.  The  various  displace- 
ments may  be  divided  into  three  groups  : — Backward  displace- 
ments ;  forward  displacements  ;  and  downward  displacements. 

Backward  Displacements. — So  far  as  the  effect  upon  preg- 
nancy is  concerned,  the  backward  displacements  of  the  uterus 
may  be  considered  together,  as  that  effect  differs  little  whether 
they  are  versions,  or  flexions,  or  both  combined.  Backward  dis- 
placements are  the  most  common  form  of  displacement  met  with 
in  pregnancy,  and  inasmuch  as  they  directly  interfere  with  the 
blood-supply  of  the  uterus  and  so  tend  to  cause  congestion,  and 

529  34 


530  THE  PATHOLOGY  OF  PREGNANCY 

under  certain    conditions  interfere  with    uterine   mobility,  their 
effects  upon  the  course  of  pregnancy  are  considerable. 

If  pregnancy  occurs  in  a  retro-deviated  uterus,  or  if  a  pregnant 
uterus  becomes  displaced  backwards,  one  or  other  of  the  following 
terminations  may  result :— Restitution  ;  abortion  ;  incarceration  ; 
or  anterior  development  of  the  uterine  wall. 

Restitution. — This  is,  fortunately,  perhaps  the  most  common 
termination  which  occurs  in  backward  displacement.  As  the 
uterus  increases  in  size,  it  rises  gradually  upwards  out  of 
Douglas's  pouch,  until,  if  nothing  prevents  it — such  as  an  over- 
hanging promontory  or  pelvic  adhesions,  the  fundus  leaves  the 
pelvis  and  comes  to  lie  in  the  position  proper  to  the  period  of 
pregnancy.  Pregnancy  then  in  all  probability  proceeds  normally. 
In  many  such  cases,  restitution  occurs  before  any  symptoms 
draw  the  patient's  attention  to  her  condition,  and  consequently 
the  displacement  is  unnoticed.  In  other  cases,  the  patient  may 
be  led  to  seek  medical  advice  owing  to  the  occurrence  of  slight 
haemorrhages  or  of  pain.  If  under  such  circumstances  backward 
displacement  is  found,  it  must  in  all  cases  be  corrected.  As  a  rule, 
there  is  no  difficulty  in  doing  this  by  the  bi-manual  method. 
If  this  method  cannot  be  carried  out  without  an  anaesthetic, 
one  must  be  administered.  Reposition  should  be  performed  at 
the  earliest  possible  moment,  as,  the  larger  the  uterus  is,  the 
greater  is  the  difficulty  of  replacing  it,  and  the  more  likely  is 
abortion  to  occur.  As  soon  as  the  uterus  has  been  replaced,  a 
properly  fitting  Smith- Hodge  pessary  must  be  inserted,  and  the 
uterus  maintained  in  position  by  this  means  until  it  has  become 
too  large  to  return  to  its  former  mal-position,  i.e.,  until  the  end  of 
the  fourth  month.  If  there  is  much  congestion  of  the  uterus,  as 
shown  by  the  recurrence  of  slight  discharges  of  blood,  small  doses 
of  ergot  and  strychnine  may  be  administered  with  advantage,  as 
will  be  presently  mentioned  when  discussing  the  treatment  of 
threatened  abortion. 

Abortion. — Abortion  is  the  most  common  termination  of  those 
cases  in  which  restitution  does  not  occur.  The  position  of  the 
uterus  tends  to  obstruct  the  venous  return,  and  so  causes 
congestion,  and  congestion  is  the  important  predisposing  cause 
of  endometritis,  which,  in  turn,  is  one  of  the  commonest  causes 
of  abortion.  In  addition  to  favouring  congestion,  backward  dis- 
placement of  the  uterus  appears  to  have  some  prejudicial  effect 
upon  the  tone  of  the  uterine  muscle.  This  is  easily  noticeable 
during  the  reposition  of  a  retro-deviated  uterus,  especially  when 
the  latter  is  pregnant.  Prior  to  reposition,  the  uterus  is  flaccid 
and  its  outline  can  be  made  out  with  difficulty ;  but,  as  soon  as  it 
is  replaced,  it  becomes  firmer  in  consistency  and  is  readily  pal- 
pable, and  this  condition  is  not  a  mere  temporary  one  due  to  the 
occurrence  of  an  intermittent  contraction,  but  is  in  great  part 
permanent,  as  can  be  determined  by  a  subsequent  bi-manual 
examination.      It  is,  we  think,   obvious  that  the  former  flaccid 


INCARCERATION  OF  THE   RETRO-DEVIATED   UTERUS       531 

condition  must  be  associated  with  an  excess  of  blood  in  the 
uterine  sinuses,  as  the  size  of  the  latter  is  probably  to  a  great 
extent  dependent  upon  the  tone  of  the  muscle  fibre,  and  this 
excess  will  in  turn  tend  to  cause  still  further  congestion  of  the 
uterus  and  to  favour  the  occurrence  of  hemorrhages  into  the 
decidua  serotina. 

Incarceration. — If  neither  of  the  foregoing  terminations  occurs, 
and  if  both  the  pregnancy  and  the  retro-deviation  persist,  the 
uterus  continues  to  develop  in  the  pelvis  until  it  fills  all  the  avail- 
able space.  As  soon  as  this  occurs,  the  pressure  which  is  pro- 
duced upon  the  neighbouring  parts  and  upon  the  uterus  by  the 
bony  pelvis  leads  to  such  extensive  alterations  in  the  nutrition  of 
these  parts,  that,  unless  the  pressure  is  speedily  removed  by  the 
reposition  or  the  emptying  of  the  uterus,  the  death  of  the  patient 
results.  To  this  condition,  the  term  incarceration  of  the  retro- 
deviated  pregnant  uterus  is  applied.  It  is  the  most  important 
termination  which  can  occur  in  these  cases,  and  consequently 
must  be  fully  discussed. 

Frequency. — Incarceration  of  the  uterus  is  a  rare  condition,  but 
it  is  not  possible  to  give  any  definite  figures  to  show  the  propor- 
tion of  cases  in  which  it  occurs.  As  retro-deviations  of  the  uterus 
are  more  frequent  amongst  multipara  than  primiparas,  incarcera- 
tion will  naturally  also  be  more  common. 

Aetiology. — We  are  not  here  discussing  the  causes  of  retro- 
deviation, as  such  matters  more  properly  concern  gynaecology 
than  obstetrics ;  we  are  only  concerned  with  the  cause  of  incar- 
ceration. Given  a  backward  displacement  of  the  uterus,  it  is 
obvious  that  the  occurrence  of  incarceration  will  be  favoured  by 
the  following  conditions  : — 

(1)  An  Overhanging  Promontory,  as  in  a  Flat  Pelvis. — The  im- 
portance of  this  condition  as  a  cause  of  incarceration  is  clearly 
shown  by  the  relatively  large  proportion  of  cases  in  which  flat 
pelvis,  or  other  pelvic  deformity  in  which  the  promontory  projects 
over  the  pelvic  cavity,  is  associated  with  incarceration.  The 
difficulties  in  the  way  of  restitution  are  then  so  greatly  increased 
that  in  all  probability  it  never  occurs  spontaneously,  and,  unless 
abortion  occurs  or  medical  treatment  is  obtained,  incarceration 
results. 

(2)  Increased  Intra-abdominal  Pressure. — If  the  uterus  is  so 
displaced  that  it  lies  on  the  floor  of  Douglas's  pouch,  the  entire 
intra-abdominal  pressure  is  acting  upon  its  upper  surface,  and 
preventing  it  from  returning  to  its  proper  position.  If  the  intra- 
abdominal pressure  is  normal,  the  growing  uterus  is  usually  able 
to  make  its  way  out  of  the  pelvis  against  it;  but,  if  it  is  unduly 
increased,  the  uterus  may  be  unable  to  do  so.  Consequently, 
all  such  conditions  as  extreme  flatulence,  abdominal  tumours,  and 
habitual  overdistension  of  the  bladder  favour  the  occurrence  of 
incarceration. 

(3)  Peritoneal  Adhesions. — If  the  fundus  is  firmly  adherent  to 

34-2 


532  THE  PATHOLOGY  OF  PREGNANCY 

the  peritoneum  of  Douglas's  pouch,  it  cannot  rise.  In  such  cases, 
abortion  is  the  most  usual  termination  of  the  case,  and,  if  this 
does  not  occur,  incarceration  results,  save  in  the  small  proportion 
of  cases  in  which  the  termination  to  which  we  shall  next  refer — 
i.e.,  anterior  development — results.  Similarly,  if  the  pelvic  cavity- 
is  roofed  over  by  adherent  intestines,  it  may  be  impossible  for 
the  displaced  uterus  to  rise.  Such  a  cause  of  incarceration  is, 
however,  perhaps  more  hypothetical  than  actual. 

Symptoms. — The  symptoms  of  an  incarcerated  retro-deviated 
uterus  will  be  readily  understood,  if  the  anatomical  changes 
which  result  from  the  condition  are  noted  (v.  Fig.  277).  Instead 
of  the  growing  uterus  rising  out  of  the  pelvis  and  pressing  less  each 
day  on  the  pelvic  contents,  as  is  normally  the  case,  the  pelvic  cavity 
is  occupied  by  a  gradually  enlarging  tumour,  which  presses  in  all 
directions.  The  resultant  symptoms  are  due  to  pressure  upon 
the  pelvic  contents,  and  become  progressively  more  severe  each 
day.  The  subjective  symptoms  are  pain,  referred  to  the  lower 
part  of  the  back,  and  running  down  the  thighs,  from  pressure 
upon  the  pelvic  nerves ;  constipation,  with  sometimes  rectal 
tenesmus,  from  pressure  upon  the  rectum  ;  difficulty  in  micturi- 
tion from  pressure  upon  the  urethra ;  and,  finally,  complete 
retention  of  urine,  passing  in  turn  to  incontinence,  the  result  of 
overdistension  of  the  bladder  (ischuria  paradoxa).  The  objective 
symptoms  are  also  the  result  of  the  growing  tumour  in  the  pelvis. 
On  making  a  vaginal  examination,  the  vagina  is  found  to  be 
displaced  forwards  by  the  pressure  of  an  elastic  tumour,  which 
fills  Douglas's  pouch  and  presses  the  pelvic  floor  downwards. 
The  vagina  is  longer  than  usual,  and  considerable  difficulty  is 
found  in  reaching  the  cervix,  which,  in  addition  to  being  displaced 
upwards,  is  also  pushed  forwards  above  the  symphysis.  If  a 
finger  is  passed  into  the  rectum,  the  latter  is  found  to  be 
flattened  out  against  the  posterior  pelvic  wall.  If  the  bladder 
is  overdistended,  a  tumour  will  be  found  on  palpation  of  the 
abdomen,  corresponding  as  a  rule  in  size  and  position  to  a  five  to 
seven  months'  pregnant  uterus.  It  is,  however,  more  elastic  than 
a  uterus  would  be,  and  no  foetal  parts  can  be  felt  nor  fcetal  heart 
heard.  This  tumour  is  formed  by  the  distended  bladder,  and 
varies  in  size  according  to  the  time  retention  has  lasted.  The 
position  of  the  urethral  orifice  will  be  found  to  be  displaced  up- 
wards, so  that  it  is  with  difficulty  that  a  catheter  can  be  passed 
into  it.  This  is  in  part  due  to  the  dragging  upwards  of  the 
anterior  vaginal  wall  owing  to  the  displacement  of  the  cervix  and 
the  consequent  traction  upon  the  cervico-vaginal  junction,  and  in 
part  to  the  distension  of  the  bladder  dragging  the  urethra  itself 
upwards.  It  is  impossible  to  make  a  bi-manual  examination  until 
the  bladder  is  emptied.  When  this  has  been  done,  the  upper 
limits  of  the  pelvic  tumour  can  be  mapped  out,  and  its  con- 
tinuity with  the  cervix  and  identity  with  the  uterus  established. 

As  a  consequence  of  the  overdistension  of  the  bladder  and  the 


INCARCERATION  OF  THE  RETRO-DEVIATED  UTERUS       533 

prolonged  retention  of  urine,  so  great  a  degree  of  interference 
with  the  nutrition  of  the  bladder-wall  may  result  that  portions  of 
the  mucous  membrane  may  be  shed  in  flakes,  and  in  some  cases 


Fig.  277.— Incarceration  of  a  Retro-flexed  Pregnant  Uterus. 
A,  Bladder  ;  B,  neck  of  bladder  ;  C,  urethra  ;  D,  cervix.    (Wyder-Schwyzer.) 

even  the  entire  mucous  membrane  be  thrown  off.     Subsequently, 
bacteria    may  pass   from   the   intestines   into   the   bladder,   and 


534  THE  PATHOLOGY  OF  PREGNANCY 

decomposition  of  the  urine  and  of  the  shed  mucous  membrane 
result,  conditions  which  may  in  turn  lead  to  a  general  septic 
peritonitis,  or  rupture  or  sloughing  through  of  the  bladder-wall 
may  occur.  If  rupture  occurs,  the  laceration  is  said  to  be  usually 
found  on  the  posterior  wall  and  near  the  fundus  ( Winckel  *).  In 
cases  of  rupture  of  the  anterior  wall,  extravasation  of  urine  into 
the  tissues  of  the  abdominal  wall  and  surrounding  parts  may  take 
place,  if  the  seat  of  the  rupture  is  below  the  line  of  peritoneal 
reflexion.  In  consequence  of  the  increase  of  tension  in  the 
bladder,  dilatation  of  the  ureters  and  of  the  pelvis  of  the  kidneys 
usually  results,  and  septic  changes  in  the  bladder  may  extend  to 
the  ureters  and  kidneys,  leading  to  the  occurrence  of  pyelo- 
nephrosis,  and  finally,  perhaps — if  the  patient  lives  long  enough 
■ — to  uraemic  poisoning  from  suppression  of  urine. 

The  wall  of  the  uterus  may  in  exceptional  cases  become 
gangrenous  in  one  or  more  places,  owing  to  the  pressure  to 
which  it  is  subjected,  with  the  result  that  an  opening  may 
form  between  the  uterus  and  the  rectum,  or  through  the  posterior 
vaginal  wall. 

Diagnosis. — As  a  rule,  the  diagnosis  of  incarceration  of  the 
uterus  is  not  difficult,  if  the  possibility  of  its  occurrence  is  present 
in  the  mind  of  the  examiner.  On  the  other  hand,  errors  have 
frequently  been  made  because  the  possibility  of  its  occurrence 
has  been  overlooked.  The  two  errors  which  are  most  usually 
made  are,  first,  mistaking  the  distended  bladder  for  a  pregnant 
uterus,  and,  secondly,  mistaking  the  retro-deviated  uterus  for  a 
tumour  in  Douglas's  pouch.  The  former  error  should  never  be 
made,  as  it  can  always  be  avoided  if  the  case  is  approached  with 
an  open  mind,  and  if  the  history  of  the  patient  has  been  obtained 
with  due  care.  It  is  a  cardinal  rule  in  all  cases  of  abdominal 
enlargement  to  ascertain  that  the  bladder  is  empty,  and  in  cases 
of  doubt  to  pass  a  catheter.  If  this  rule  is  followed,  either  the 
bladder  will  be  emptied  and  the  tumour  will  disappear,  or  the 
impossibility  of  passing  a  catheter  will  immediately  suggest  the 
nature  of  the  case.  The  second  error  is  more  difficult  to  avoid  ; 
indeed,  in  some  cases  it  will  be  impossible  to  say  what  is  the 
exact  nature  of  the  pelvic  tumour  save  by  carefully  examining 
the  patient  under  an  anaesthetic.  There  are  three  conditions 
which  may  be  readily  confounded  with  incarceration  of  the 
pregnant  uterus.  These  are  a  myomatous  uterus  or  an  ovarian 
cyst  impacted  in  the  pelvis,  or  a  retro-uterine  hsematocele.  In 
a  myomatous  uterus,  the  history  shows  that  instead  of  a  period 
of  amenorrhcea,  the  patient  complains  of  menorrhagia,  and  that 
the  other  subjective  and  objective  symptoms  of  pregnancy  are 
absent.  The  uterus  is  firmer  than  a  pregnant  uterus  would  be, 
and  is  usually  somewhat  irregular  in  outline.  In  the  case  of  an 
ovarian  cyst,  the  uterus  can  be  found  anteposed  to   the   tumour 

*  Op.  tit.,  p.  237. 


INCARCERATION  OF  THE  RETRO-DEVIATED   UTERUS       535 

in  Douglas's  pouch.  The  history  of  the  case  is  also  opposed  to 
the  idea  of  pregnancy,  and  the  subjective  and  objective  symptoms 
are  wanting.  A  retro-uterine  hematocele  is  the  most  likely  to  be 
a  source  of  error,  inasmuch  as  it  is  usually  the  result  of  pregnancy, 
and  as  in  consistency  it  sometimes  resembles  a  pregnant  uterus. 
The  most  important  points  of  difference  are  the  absence  of  any 
displacement  of  the  orifice  of  the  urethra — as  a  hematocele  in 
Douglas's  pouch  will  not  cause  any  upward  traction  on  the 
anterior  vaginal  wall,  and  the  fact  that  the  uterus  can  be  found 
on  careful  bi-manual  examination  anteposed  to  the  pelvic  tumour. 
Further,  retention  of  urine  rarely  occurs  in  the  case  of  a  hema- 
tocele, and  a  history  of  the  sudden  onset  of  pain,  followed  by 
collapse — i.e.,  the  history  of  the  rupture  of  an  extra-uterine 
pregnancy — is  usually  forthcoming.  A  correct  diagnosis  in  these 
cases  is  of  the  greatest  importance,  as  the  dangers  which  result 
from  a  mistake  are  very  great.  An  incarcerated  uterus  must  be 
replaced,  if  possible,  but  the  '  reposition  '  of  a  hematocele,  which, 
perhaps,  was  undergoing  decomposition,  might  be  attended  by 
fatal  consequences,  as  will  be  readily  understood.  The  impor- 
tance of  the  upward  displacement  of  the  orifice  of  the  urethra  as 
a  distinguishing  sign  which  is  alone  found  in  the  case  of  an  in- 
carcerated gravid  uterus  was  pointed  out  by  Roper  during  a 
discussion  at  the  London  Obstetrical  Society  in  1874.  Its 
occurrence  is  due  to  the  attachments  of  the  pelvic  tumour  to  the 
vagina  at  the  cervico-vaginal  junction,  and,  though  eminently 
characteristic  of  an  incarcerated  pregnant  uterus,  it  may  also 
occur  in  cases  of  uterine  enlargement  from  other  causes,  such  as 
myomata. 

Treatment. — The  treatment  of  incarceration  may  be  summarised 
in  a  few  words.  The  bladder  must  be  emptied,  and  the  uterus 
replaced,  if  possible  without  interfering  with  the  course  of 
pregnancy.  If  this  is  impossible,  the  uterus  must  be  first 
emptied,  and  then  replaced. 

The  difficulties  in  the  way  of  carrying  out  the  first  step  of  this 
procedure — i.e.,  the  emptying  of  the  bladder — have  been  already 
referred  to,  as  well  as  the  manoeuvres  by  which  they  may  be 
overcome.  If  all  attempts  at  the  passage  of  a  catheter  fail,  the 
bladder  must  be  punctured  supra-pubically,  and  thus  emptied. 

As  soon  as  the  bladder  is  emptied,  the  reposition  of  the  uterus 
is  attempted.  At  first,  we  endeavour  to  do  this  in  the  ordinary 
manner — i.e.,  by  upward  pressure  upon  the  fundus  in  the  axis 
of  the  pelvis,  with  two  fingers  in  the  vagina,  and  the  patient  in 
the  dorsal  position.  If  this  fails,  as  will  probably  be  the  case, 
one  or  two  fingers  are  introduced  into  the  rectum  and  pressure 
made  upon  the  fundus.  In  the  ordinary  run  of  cases,  reposition 
will  be  thus  accomplished,  especially  if  the  patient  is  first  placed 
under  an  anesthetic.  The  importance  of  pushing  the  fundus  to 
one  or  other  side  of  the  promontory  so  as  to  get  clear  of  this 
projection,  and  thus  gain  more  room,  was  first  pointed  out  by 


536  THE  PATHOLOGY  OF  PREGNANCY 

Skinner,*  and  is  insisted  upon  by  Barnes,  f  It  is  a  very  essential 
line  of  procedure  in  cases  of  flattened  pelvis,  but  in  the  case  of 
a  normal  pelvis,  we  doubt  that  much  advantage  is  gained  by 
adopting  such  a  course,  while,  if  the  uterus  fills  the  pelvis,  it  is 
impossible.  If  our  efforts  at  reposition  are  still  unsuccessful,  a 
further  attempt  may  be  made  with  the  patient  in  the  knee-chest 
position.  This  position  undoubtedly  favours  reposition,  but  the 
difficulty  of  maintaining  a  patient  in  it  and  at  the  same  time  ad- 
ministering an  anaesthetic  are  very  considerable,  unless  we  have 
special  apparatus  at  hand  or  numerous  assistants,  and  if  a  choice 
has  to  be  made  between  the  knee-chest  position  and  anaesthesia, 
we  prefer  the  latter. 

Cases  have  been  recorded  in  which  reposition  has  been  ob- 
tained by  the  use  of  a  colpeurynterj  (Playfair),  and  by  the  inser- 
tion of  a  watch-spring  pessary  (Japp  Sinclair).  Moreover,  cases 
have  been  recorded  in  which  reposition  occurred  spontaneously 
after  manual  efforts  had  failed.  We  confess,  however,  that  we 
are  very  sceptical  as  to  success  attending  such  measures  in  cases 
where  previous  manual  attempts  had  been  regularly  and  properly 
carried  out  under  anaesthesia,  and  had  failed.  The  failure  of 
attempts  at  reposition  made  with  the  patient  in  the  side  position 
and  without  the  administration  of  an  anaesthetic  do  not,  however, 
prove  that  the  displacement  is  irreducible,  and  we  fancy  that  it  is 
in  such  cases  that  hydrostatic  dilators  and  such  like  procedures 
have  succeeded.  It  is  possible  that  the  use  of  Walcher's  position 
might  be  of  value,  on  account  of  the  increase  in  the  width  of  the 
conjugate  diameter  which  it  causes. 

If  the  uterus  cannot  be  replaced,  it  must  be  emptied.  The 
best  method  of  doing  so  consists  in  inducing  abortion,  but  here 
again  difficulties  are  met  with.  The  readiest  means  of  inducing 
abortion  consists  in  puncturing  the  membranes  with  a  sound  or 
stylette  introduced  through  the  cervical  canal.  But,  on  account 
of  the  upward  displacement  of  the  cervix,  it  is  almost  impossible 
to  get  the  sound  into  the  cervical  canal,  or  if  we  succeed  in  doing 
this,  to  then  pass  it  onwards  into  the  uterus,  on  account  of  the 
downward  bend  of  the  axis  of  the  uterine  cavity.  An  ingenious 
method  of  passing  a  stylette  has  been  suggested  and  successfully 
practised.  It  consists  in  cutting  the  ends  off  a  metal  male 
catheter,  in  such  a  manner  as  to  leave  a  straight  portion  of 
sufficient  length  to  reach  from  the  vulva  to  the  cervical  orifice, 
and  enough  of  the  curved  portion  to  reach  from  the  external  to 
the  internal  os.  The  angle  of  the  curve  may  be  slightly  accen- 
tuated by  bending  until  it  is  adjusted  to  the  angle  which  the 
cervical   canal    makes    with   the   vagina.     The   catheter  is  then 

*  Brit.  Med.  Journ.,  i860. 

f  '  Obstetric  Operations,'  third  edition,  p.  276. 

I  A.  pear-shaped  rubber  bag  which  is  introduced  into  the  vagina  and  filled 
with  water.  It  exercises  a  gentle  and  continuous  pressure  upon  the  surround- 
ing parts. 


ANTERIOR  DEVELOPMENT  OF  RETRO-DEVIATED  UTERUS     537 

slipped  up  into  the  vagina  and  guided  with  the  finger  up  to  the 
cervical  orifice,  into  which  the  curved  end  is  slipped.  A  stylette 
made  of  soft  metal  is  then  pushed  along  the  catheter  by  which  it 
is  guided  into  the  internal  os.  It  is  then  cautiously  passed  through 
the  latter,  and  the  membranes  punctured.  If  we  fail  to  puncture 
the  membranes  even  by  this  means,  a  fine  trochar  and  canula 
must  be  passed  through  the  posterior  vaginal  wall  into  the  uterus 
and  the  liquor  amnii  drawn  off.  If  proper  aseptic  precautions 
are  taken  there  is  no  danger  in  such  a  procedure,  and  it  will  effect 
such  a  reduction  in  the  size  of  the  uterus  that  reposition  may  be 
possible.  Then  if  contractions  do  not  occur  and  expel  the  ovum, 
the  cervix  must  be  dilated  and  the  latter  removed. 

As  soon  as  the  uterus  has  been  replaced,  a  Smith-Hodge  pessary 
of  a  suitable  size  is  inserted  in  order  to  maintain  it  in  position.  If 
pregnancy  continues,  the  pessary  should  be  left  in  until  the  end 
of  the  fourth  month,  when  it  may  be  removed,  as  the  uterus  will 
then  be  too  large  to  again  become  displaced. 

Prognosis. — The  prognosis  of  these  cases  is  good  if  the  con- 
dition is  recognised  before  any  pressure  necrosis  of  the  uterus 
or  surrounding  parts,  or  any  sloughing  of  the  bladder  wall  has 
occurred,  and  if  reposition  is  possible.  Once  either  of  these 
complications  have  occurred  the  prognosis  becomes  serious,  in 
accordance  with  the  extent  to  which  the  necrosis  or  sloughing 
have  gone.  If  an  incarcerated  uterus  remains  untreated  and 
abortion  does  not  occur,  the  most  favourable  termination  that  can 
be  hoped  for  is  the  escape  of  the  contents  of  the  uterus  through 
an  opening,  the  result  of  sloughing,  between  the  uterus  and  the 
vagina  or  rectum. 

Anterior  Development. — The  rarest  of  all  the  terminations  of 
backward  displacement  of  the  pregnant  uterus  is  that  known  as 
anterior  development  of  the  uterine  wall.  In  this  condition,  the 
posterior  wall  of  the  uterus,  which  is  in  contact  with  the  floor  of 
Douglas's  pouch,  is  kept  in  that  position  either  by  adhesions  or  by 
an  overhanging  promontory,  while,  at  the  same  time,  sufficient 
development  of  the  anterior  uterine  wall  takes  place  to  allow 
room  for  the  growing  foetus.  The  result  of  this  is  that  at  the  end 
of  pregnancy  the  cervix  is  situated  higher  than  normal,  and  is 
pushed  forwards  above  the-  symphysis.  The  main  part  of  the 
uterus  is  found  in  its  normal  position,  but  behind  the  vagina  and 
below  the  cervix  is  found  a  uterine  pouch  which  fills  Douglas's 
pouch.  To  this  condition,  the  terms  sacculation  of  the  uterus  and 
partial  retroversion  have  also  been  applied.  It  is  analogous  to 
a  somewhat  similar  condition  to  which  we  shall  presently  refer, 
in  which  a  uterine  pouch  is  found  anterior  to  the  cervix. 

Symptoms. — In  the  early  months,  the  symptoms  are  akin  to 
those  of  incarceration,  but,  as  anterior  development  of  the 
uterine  wall  takes  place,  they  pass  off  and  no  further  symptoms 
occur  until  labour  commences.  Then,  on  examining  the  patient, 
the  presence  of  the  pelvic  pouch  containing  the   lower  pole  of 


538  THE  PATHOLOGY  OF  PREGNANCY 

the  foetus  is  discovered,  as  well  as  the  high  situation  of  the 
uterine  orifice.  The  effects  of  the  condition  upon  the  mechanism 
of  labour  depend  upon  the  size  of  the  pelvic  pouch.  If  the 
latter  is  large  and  allows  the  lower  pole  of  the  foetus  to 
descend  into  it,  it  is  obvious  that  delivery  will  be  most 
difficult,  as  the  presenting  foetal  pole  will  be  unable  to  enter 
the  uterine  orifice,  and  consequently  there  will  be  no  presenting 
part  to  dilate  the  uterine  orifice.  Further,  all  manipulation  with 
the  object  of  delivering  the  foetus  will  be  most  difficult,  on  account 
of  the  compression  of  the  vagina  between  the  symphysis  and 
whatever  part  of  the  foetus  is  found  in  the  pelvic  pouch. 

Diagnosis. — The  diagnosis  of  the  condition  is  readily  made. 
Possibly,  confusion  may  arise  between  it  and  an  ovarian  cyst 
which  has  descended  into  the  pelvis  below  the  presenting  part. 
It  will,  however,  be  easy  to  determine  that,  in  the  latter  case,  the 
fluid  in  the  pelvic  tumour  is  not  continuous  with  the  fluid  in  the 
uterus,  and  also  that  the  pelvic  tumour  does  not  contain  a  foetal 
part. 

Treatment.  —  The  treatment  of  these  cases  more  correctly 
belongs  to  the  pathology  of  labour,  but,  inasmuch  as  such  a 
course  would  necessitate  separating  them  from  incarceration 
of  the  uterus,  we  prefer  to  discuss  them  here.  Barnes  suc- 
ceeded in  pushing  up  the  pelvic  pouch  and  bringing  down  the 
cervix,  and  then  delivering  the  foetus  by  the  forceps,  or  by 
turning  it  into  a  breech  presentation,  drawing  down  a  leg,  and 
applying  traction  to  the  latter — the  necessary  dilatation  of  the 
cervix  in  either  case  having  been  first  obtained  by  the  use  of 
hydrostatic  dilators.  If  such  a  course  is  possible  it  is  the  most 
suitable  one  to  adopt.  If,  however,  the  pelvic  pouch  cannot  be 
replaced,  nor  sufficient  dilatation  of  the  cervix  obtained  to  enable 
version  and  extraction  to  be  performed,  the  only  alternative  is 
Caesarean  section.  If  this  operation  is  necessary,  it  may  be 
carried  out  either  by  the  abdominal  route,  or  by  the  vaginal 
route  as  recommended  by  Diihrssen.  The  latter  route  seems . 
to  offer  certain  advantages  in  these  cases,  on  account  of  the  close 
approximation  of  the  uterine  and  posterior  vaginal  walls. 

Forward  Displacements. — The  normal  position  of  the  non- 
pregnant uterus  is  one  of  complete  anteversion  and  slight  ante- 
flexion. In  consequence,  it  lies  almost  horizontally  in  the  pelvis 
when  the  bladder  is  empty,  its  anterior  or  lower  surface  in  contact 
with  the  latter  organ,  and  the  tip  of  the  cervix  on  a  level  with  the 
lines  joining  the  ischiatic  spines.  As  pregnancy  advances,  the 
fundus  rises  upwards,  and  by  the  fourth  month  the  previous  ante- 
version  has  almost  or  entirely  disappeared.  Later,  a  slight  degree 
of  anteversion  reappears  owing  to  the  falling  forward  of  the 
uterus  against  the  abdominal  walls.  The  exact  degree  depends 
upon  the  laxity  and  strength  of  the  abdominal  walls. 

Two  forms  of  forward  displacement  may  occur  during  preg- 


PATHOLOGICAL  ANTEFLEXION  OF  THE  PREGNANT  UTERUS    539 

nancy  : — A  pathological  degree  of  anteflexion  and  a  pathological 
degree  of  anteversion. 

Pathological  Anteflexion. — The  normal  anteflexion  of  the  uterus 
is  due  to  the  fact  that  the  weight  of  the  uterine  body  causes  the  latter 
to  fall  downwards  until  it  meets  with  the  support  of  the  bladder.  As 
soon  as  any  upward  force,  such  as  the  pressure  of  the  distending 
bladder,  begins  to  make  itself  felt,  the  body  is  pushed  up  and  the 
anteflexion  disappears.  In  pathological  anteflexion,  the  body  of 
the  uterus  makes  a  sharper  angle  with  the  cervix  than  is  normal, 
and  at  the  same  time,  owing  to  the  rigidity  of  the  uterine  tissue 
or  to  other  causes,  such  as  the  fixation  of  the  body  by  adhesions, 
upward  movement  of  the  body  as  the  bladder  fills  does  not 
occur. 

Aetiology. — This  condition  may  result  from  three  causes: — 

(1)  Congenital  Mal-development  of  the  Uterus. — In  such  cases, 
either  pregnancy  does  not  occur  at  all  owing  to  an  accompanying 
undeveloped  condition  of  the  ovaries,  or  if  it  does  the  displace- 
ment of  the  uterus  disappears  as  the  latter  organ  enlarges.  Con- 
sequently, the  obstetrical  importance  of  such  cases  is  nil. 

(2)  The  Result  of  Inflammation. — Pelvic  peritonitis  resulting 
in  the  formation  of  adhesions  between  the  isthmus  of  the  uterus 
and  the  sacrum,  and  resulting  in  the  dragging  backwards  of  the 
isthmus  while  leaving  the  fundus  free,  is  a  common  cause  of 
pathological  anteflexion  in  the  non-pregnant  state.  As,  however, 
the  fundus  is  free,  such  cases  do  not  possess  any  great  obstetrical 
interest.  More  rarely,  pelvic  peritonitis  may  result  in  the  forma- 
tion of  adhesions  between  the  fundus  and  the  peritoneum  covering 
the  bladder.  In  such  cases,  the  fundus  is  not  free  to  rise  during 
pregnancy,  and,  consequently,  complications  may  occur. 

(3)  The  Result  of  Operative  Interference. — In  the  operation 
known  as  vaginal  fixation  of  the  uterus  for  the  cure  of  backward 
displacements,  it  was  at  one  time  customary  to  suture  the  fundus 
of  the  uterus  to  the  anterior  vaginal  wall.  Such  a  procedure 
resulted  in  the  production  of  an  extreme  degree  of  fixed  ante- 
flexion, and  interfered  with  the  rising  of  the  uterus  during 
pregnancy,  with  the  result  that  serious  complications  resulted 
during  pregnancy  and  labour.  It  is,  moreover,  an  unnecessary 
operation,  as  the  same  results  can  be  obtained  by  suturing,  not 
the  fundus,  but  a  point  a  little  above  the  isthmus  to  the  vaginal 
wall,  and  in  this  way  bringing  the  uterus  into  a  more  correct 
position. 

Symptoms. — When  the  fundus  of  the  uterus  is  fixed  in  a 
position  of  anteflexion,  its  development  during  pregnancy  is 
interfered  with.  In  consequence,  in  some  cases,  abortion 
results,  while,  in  other  cases,  a  posterior  development  of  the 
body  takes  place  analogous  to  the  anterior  development,  which 
has  been  described  as  occurring  when  the  fundus  is  fixed  in 
Douglas's  pouch,  while  a  pouch  or  anterior  sacculation  persists 
between  the  cervix  and  the  symphysis.     As  the  posterior  wall 


540  THE  PATHOLOGY  OF  PREGNANCY 

develops  to  accommodate  the  growing  foetus,  the  cervix  becomes 
drawn  upwards  and  backwards,  until  finally  it  lies  high  up  in  the 
hollow  of  the  sacrum,  where  it  is  difficult  or  impossible  to  reach 
it  with  the  fingers. 

This  condition  produces  few  symptoms  during  pregnancy. 
There  may  possibly  be  some  interference  with  the  distension  of 
the  bladder,  with  resultant  frequent  micturition.  When,  how- 
ever, the  patient  comes  into  labour,  difficulties  may  result  similar 
to  those  which  have  been  described  when  discussing  the  analo- 
gous condition  of  posterior  sacculation.  The  presenting  pole 
of  the  foetus  descends  into  the  anterior  pouch,  and,  consequently, 
both  the  dilatation  of  the  os  and  the  passage  of  the  foetus  out  of 
the  uterus  are  interfered  with.  If  such  a  case  is  examined 
vaginally,  the  presenting  part  covered  by  uterine  wall  is  found  in 
the  pelvis,  and  pushes  the  vagina  downwards  and  backwards. 
It  may  be  possible  to  pass  the  finger  above  it  and  so  to  reach  the 
cervix,  but,  on  the  other  hand,  if  the  presenting  part  has  descended 
deeply  and  fills  the  pelvis,  such  a  course  may  be  impossible. 

Diagnosis. — -The  only  condition  for  which  anterior  sacculation 
of  the  uterus  can  be  mistaken  is  the  rather  problematical  one 
of  complete  acquired  occlusion  of  the  uterine  orifice,  as  in  both 
conditions  the  cervix  fails  to  dilate.  Here,  however,  the  resem- 
blance ceases,  as  in  acquired  occlusion  of  the  orifice  some  trace 
of  cervix  can  be  found  in  its  normal  position,  while  in  anterior 
sacculation  of  the  uterus  the  cervix  is  drawn  upwards  and 
backwards. 

Treatment. — In  some  cases,  where  the  presenting  part  is  not 
fixed,  it  may  be  possible  to  push  up  the  anterior  pouch,  as  has 
been  done  in  the  case  of  a  posterior  pouch,  and  to  draw  down 
the  cervix.  If  this  can  be  done,  the  pouch  can  be  then  main- 
tained in  position  by  a  firm  vaginal  tampon,  until  such  time  as 
the  cervical  canal  is  sufficiently  dilated  to  permit  of  the  passage 
of  the  presenting  part.  If  it  cannot  be  done,  an  attempt  must  be 
made  to  dilate  the  cervix  with  hydrostatic  dilators,  and,  as  soon 
as  a  sufficient  degree  of  dilatation  has  been  obtained,  podalic 
version  should  be  performed  and  a  leg  drawn  down.  If  the 
anterior  pouch  is  of  small  size,  and  the  uterine  orifice  already 
partially  dilated,  it  may  be  possible  to  draw  down  the  cervix 
below  the  presenting  part  by  hooking  one  or  two  fingers  into  the 
orifice.  Each  contraction  of  the  uterus  then  drives  the  presenting 
part  more  deeply  into  the  orifice,  and,  finally,  the  cervix  will  retract 
upwards  over  the  presenting  part.  If,  on  the  other  hand,  the 
anterior  pouch  is  so  deep,  and  the  displacement  of  the  cervix  so 
marked  that  it  is  impossible  to  reach  the  latter,  a  choice  must  be 
made  between  abdominal  or  vaginal  Cesarean  section.  As  a 
rule,  perhaps,  the  latter  operation  will  be  more  easily  performed. 
These  cases  are,  however,  of  such  extreme  rarity,  that  it  is 
difficult  to  lay  down  a  definite  rule  for  treating  them. 

Prognosis. — If  the  condition  is  not  relieved,  and  labour  is  allowed 


PATHOLOGICAL  ANTEVERSION  OF  THE  PREGNANT  UTERUS  541 

to  continue,  it  is  possible  that,  in  some  cases,  the  retraction  of 
the  uterus  may  result  in  drawing  up  the  cervix  over  the  presenting 
part,  and  so  causing  the  anterior  pouch  to  disappear.  On  the 
other  hand,  if  this  does  not  happen,  the  uterus  will  almost 
certainly  rupture,  and  the  foetus  be  expelled  through  a  rent  in  the 
floor  of  the  pouch.  Consequently,  in  all  such  cases  the  course  of 
labour  must  be  carefully  watched.  If  the  case  is  correctly 
treated,  there  is  no  reason  that  both  mother  and  foetus  should 
not  be  saved. 

Pathological  Anteversion.  —  A  pathological  degree  of  anteversion 
is  said  to  exist  when  the  normal  anteversion  is  exaggerated  or 
is  permanent,  so  that  the  uterus  cannot  be  pushed  upwards 
by    the    distension    of    the   bladder,    and   when   the   rigidity    of 


Fig.  278. — A  Pendulous  Abdomen. 

the  uterine  tissue  is  so  increased  that  the  normal  degree  of 
flexion  cannot  occur.  In  pregnancy,  pathological  anteversion 
can  scarcely  be  considered  to  occur  before  the  uterus  has  passed 
out  of  the  pelvis,  and  then  it  consists  in  an  excessive  forward 
inclination  of  the  axis  of  the  uterine  body,  so  that  the  axis 
becomes  horizontal,  or  even  lies  higher  posteriorly  than  anteriorly. 
To  this  condition,  the  term  '  pendulous  abdomen  '  is  also  applied. 
ALtiology. — Pathological  anteversion  of  the  pregnant  uterus,  or 
pendulous  abdomen,  is  the  result  of  the  abdominal  walls  failing 
to  withstand  the  force  with  which  the  uterus  presses  against 
them.  This  condition  may  therefore  result,  either  from  the 
increased  force  with  which  the  uterus  presses  against  the  walls, 
or  from  the  diminished  strength  of  the  walls.    The  uterus  presses 


542  THE  PATHOLOGY  OF  PREGNANCY 

with  increased  force  against  the  abdominal  wall  in  cases  of 
contracted  pelvis,  owing  to  the  fact  that  it  is  pushed  upwards  out 
of  the  pelvis  by  the  narrow  brim,  and  that  in  consequence  it 
tends  to  fall  forwards  against  the  abdominal  wall ;  in  cases  of 
multiple  pregnancy  and  tumours,  owing  to  the  increased  size  of 
the  uterus  ;  and  in  marked  lordosis,  owing  to  the  forward  dis- 
placement of  the  uterus.  The  normal  tone  or  resistance  of  the 
abdominal  walls  is  diminished  as  a  result  of  previous  overdis- 
tension, as  in  the  case  of  previous  multiple  pregnancies,  hydram- 
nios,  or  multij  arity  ;  of  the  yielding  of  the  cicatrix  of  an  abdominal 
incision  ;  and  sometimes  as  the  result  of  muscular  wasting  or 
insufficient  development,  the  result  of  mal-nutrition,  or  long- 
continued  illness. 

Symptoms. — If  the  uterus  is  fixed  in  a  position  of  anteversion, 
it  may  give  rise  to  slight  irritability  of  the  bladder  during  the  first 
three  months.  Later,  as  the  more  important  anteversion  of 
pregnancy  orcurs,  the  patient  finds  it  difficult  to  walk  owing  to 
the  alteration  in  the  position  of  her  centre  of  gravity.  At  the 
same  time,  the  stretching  of  the  skin  gives  rise  to  pain,  excoria- 
tions occur  as  the  result  of  the  rubbing  together  and  moisture 
of  the  skin,  oedema  of  the  abdominal  walls  results  from  the 
dependent  position,  and  constipation  and  difficulty  of  defalcation 
from  the  lessened  intra-abdominal  pressure.  The  appearance  of 
the  patient  is  characteristic,  especially  when  she  stands  upright. 
If  the  recti  muscles  are  widely  separated,  the  uterus  may  project 
through  them,  causing  a  more  or  less  conical  tumour.  To  this 
condition,  the  term  '  eventration  '  is  applied. 

The  effects  of  a  pendulous  abdomen  on  labour  are(  numerous 
and  important.  Anomalies  in  the  lie  and  presentation  of  the 
foetus  are  of  common  occurrence  owing  to  the  altered  position  of 
the  uterus,  the  loss  of  the  support  which  the  presenting  head 
normally  receives  from  the  pelvic  brim,  and  the  alteration  in  the 
relation  between  the  axis  of  the  uterus  and  the  axis  of  the  pelvic 
brim.  The  course  of  labour  is  also  prolonged,  owing  to  the 
failure  of  the  voluntary  contractions  of  the  abdominal  muscles, 
and  to  the  slow  engagement  of  the  head,  which  is  driven  against, 
instead  of  into,  the  pelvic  brim. 

Treatment. — In  all  cases  in  which  the  abdominal  walls  are 
lax,  the  patient  should  wear  a  properly  fitting  abdominal  belt 
during  pregnancy.  Due  attention  to  this  precaution  will  prevent 
the  increased  laxity  of  the  walls,  which  will  otherwise  result 
from  each  successive  pregnancy.  Indeed,  we  consider  that 
it  is  advisable  for  every  pregnant  woman  to  wear  a  proper 
abdominal  support,  at  any  rate  during  the  last  three  months  of 
pregnancy,  as  a  prophylactic  measure,  unless  the  development  of 
the  abdominal  muscles  is  exceptionally  well  marked.  The  patient 
should  remain  in  bed  during  the  entire  period  of  labour,  and  should 
lie  as  much  as  possible  upon  her  back.  At  the  same  time,  an 
abdominal  binder  must  be  pinned  tightly  round  the  abdomen  in 


PROLAPSE  AND  PROCIDENTIA  OF  THE  PREGNANT  UTERUS    543 

such  a  manner  as  to  bring  the  axis  of  the  uterus  as  nearly  as 
possible  into  correspondence  with  the  axis  of  the  pelvic  brim. 
All  complications  of  presentation,  etc.,  must  of  course  be 
corrected. 

Downward  Displacements. — Under  the  head  of  downward 
displacements  we  shall  discuss  three  conditions  which  are  closely 
associated  with  one  another.  These  are  : — Prolapse  and  proci- 
dentia of  the  uterus  ;  prolapse  of  the  vaginal  walls  ;  hypertrophy 
of  the  cervix. 

Prolapse  and  Procidentia  of  the  Uterus. — A  uterus  is  said  to  be 
prolapsed  when  it  has  descended  into  the  vagina  ;  procidentia  of 
the  uterus,  on  the  other  hand,  is  the  term  applied  to  the  condi- 
tion when  the  uterus  has  in  part  or  altogether  passed  outside  the 
vulva.  Pregnancy  has  relatively  frequently  occurred  in  prolapse, 
and  cases  of  its  occurrence  in  procidentia  have  also  been  recorded. 
In  the  older  writers,  cases  have  been  recorded  in  which,  at  full 
term,  a  pregnant  uterus  has  been  found  completely  outside  the 
pelvic  cavity,  but  such  cases  are  rightly  regarded  as  imaginary. 
If  pregnancy  occurs  in  a  case  of  complete  procidentia,  either 
abortion  results  or  the  patient  seeks  medical  aid  and  the  uterus 
is  replaced. 

Spiegelberg  stated  that  when  pregnancy  occurs  in  a  case  of 
downward  displacement  of  the  uterus  three  courses  are  possible : — 

(1)  As  the  uterus  increases  in  size,  it  rises  and  the  prolapse 
disappears.  This  is,  perhaps,  the  most  common  termination.  If 
the  prolapse  was  associated  with  hypertrophy  of  the  cervix,  the 
latter  may  still  protrude  through  the  vulva,  accompanied  or  not 
by  prolapse  of  the  vagina. 

(2)  The  uterus  may  develop  in  the  pelvic  cavity,  and  become 
incarcerated  there,  leading  to  the  occurrence  of  similar  results 
and  consequences  to  those  already  enumerated  under  the  head 
of  incarcerated  retroverted  uterus,  and  causing  the  death  of  the 
mother  if  abortion  does  not  take  place  or  if  the  uterus  is  not 
replaced. 

(3)  A  great  part  of  the  prolapsed  uterus  passes  entirely  outside 
the  pelvis,  the  ovum  remaining  in  the  part  which  is  still  inside 
the  pelvis.  In  such  cases,  unless  artificial  or  spontaneous  reposi- 
tion occurs,  abortion  or  incarceration  of  the  part  of  the  uterus 
which  contains  the  ovum  will  result. 

To  these  three  terminations  a  fourth  may  be  added.  The 
pregnant  uterus  may  remain  wholly  outside  the  vulva  until  the 
third  or  fourth  month.  Then  either  abortion  occurs  or  the  uterus 
becomes  strangulated  and  sloughs. 

Symptoms. — If  pregnancy  occurs  in  a  prolapsed  uterus  all  the 
symptoms  ordinarily  produced  by  prolapse  will  be  accentuated. 
If  the  cervix  is  outside  the  vulva,  its  ulceration  is  almost  certain 
to  occur,  while  the  exposure  to  the  air  and  the  constant  friction 
against  the  skin  and  clothes  of  the  patient  will  lead  to  alterations 


544  THE  PATHOLOGY  OF  PREGNANCY 

in  its  consistency  which  may  have  serious  consequences  during 
labour.     They  will  be  referred  to  presently. 

Treatment. — A  prolapsed  uterus  must  be  immediately  replaced, 
and  maintained  in  position  either  by  the  use  of  frequently  changed 
tampons  or  the  insertion  of  a  suitable  ring  or  Smith-Hodge  pessary. 
If  reposition  is  impossible  owing  to  the  size  of  the  uterus,  abortion 
must  be  induced,  and  the  uterus  then  replaced. 

Prolapse  of  the  Vaginal  Walls. — This  condition  is  almost 
invariably  associated  with  a  greater  or  less  degree  of  prolapse, 
and  may  persist  even  after  the  prolapsed  uterus  has  been 
replaced.  In  consequence  of  the  exposure  of  the  mucous  mem- 
brane, important  changes  in  the  nutrition  and  nature  of  the 
latter  may  occur  leading  to  ulceration  and  thickening.  The 
importance  of  preventing  either  of  these  conditions  from  occurring 
is  obvious,  as  it  is  a  serious  matter  to  have  ulcerated  and 
probably  septic  surfaces  in  so  close  proximity  to  the  uterus 
during  labour,  while  the  thickening  of  the  vaginal  walls  will 
prevent  their  dilatation  during  labour  and  lead  to  the  occurrence 
of  lacerations. 

Treatment. — In  most  cases,  the  reposition  of  the  uterus  will  lead 
to  the  reposition  also  of  the  vaginal  walls.  The  mucous  mem- 
brane of  the  latter  must  be  then  brought  back  to  a  normal  condi- 
tion by  hot  douches,  and  the  use  of  vaginal  tampons  soaked  in  a 
ten  per  cent,  solution  of  ichthyol  in  glycerine.  When  the  vaginal 
walls  prolapse  even  after  the  reposition  of  the  uterus  and  the 
insertion  of  a  pessary,  they  must  be  kept  in  place  and  protected 
from  friction,  etc.,  by  a  soft  pad  supported  by  a  perinaeal  band. 

Hypertrophy  of  the  Cervix. — Hypertrophy  of  the  cervix  may 
be,  and  usually  is,  associated  with  prolapse  of  the  uterus,  or,  on 
the  other  hand,  it  may  exist  alone  as  a  congenital  condition.  If 
the  hypertrophy  is  considerable,  the  cervix  may  protrude  through 
the  vulva.  The  importance  of  this  condition  lies  in  the  fact  that 
changes  occur  in  the  tissues  of  the  cervix  which  render  its  dilata- 
tion during  labour  very  slow.  These  changes  are  particularly 
marked  in  cases  in  which  the  cervix  has  passed  outside  the  vulva, 
as  there  then  is  usually  a  chronic  inflammation  and  induration  of 
the  muscle  fibres.  Moreover,  ulceration  of  the  exposed  portion 
of  the  cervix  usually  occurs  and  may  be  accompanied  by  a  puru- 
lent discharge.  Smyly  records  a  case*  which  occurred  in  the 
Rotunda  Hospital,  in  which  a  patient  was  admitted  at  full  term 
with  a  long-standing  prolapse  of  the  cervix.  Labour  ensued,  and 
had  not  lasted  for  more  than  six  hours  when  the  uterus  ruptured 
in  consequence  of  the  obstruction  offered  to  the  expulsion  of  the 
foetus,  with  fatal  results. 

Treatment. — When  hypertrophy  of  the  cervix  is  detected  during 

pregnancy,  and  particularly  when  the  cervix  has  passed  outside 

the  vulva,  every  effort  must  be  made  to  bring  back  the  tissues  as 

far  as  possible  to  their  normal  condition.     If  the  uterus  is  pro- 

*  '  Report  of  the  Rotunda  Hospital,'  1890-91. 


HYPERTROPHY  OF  THE  CERVIX 


545 


lapsed,  it  must  be  replaced  and  maintained  in  position  by  means 
of  a  pessary  or  a  tampon.  At  the  same  time,  attempts  must  be 
made  to  soften  the  tissues  of  the  cervix  and  to  cure  any  ulcera- 
tions present.  For  this  purpose,  tampons  of  cotton-wool  soaked 
in  glycerine  and  ichthyol  are  placed  in  the  vagina.  Hot  vaginal 
douches  may  also  be  occasionally  given,  and  hot  hip-baths  ad- 
ministered. If  the  cervix  remains  prolapsed  outside  the  vulva, 
even  after  the  uterus  is  replaced,  or  if  there  is  a  marked  degree 
of  hypertrophy,  the    question    of   operative    measures  with    the 


Fig. 


279. — Prolapse    of    the    Hypertrophied    Cervix    at    the    Eighth 
Month  of  Pregnancy.     (Bumm.) 


object  of  removing  the  redundant  portion  must  be  discussed. 
Winckel  and  Schroeder  both  agree  in  recommending  such  a 
course,  at  any  rate  during  the  early  part  of  pregnancy.  There 
can  be  little  doubt  that  the  chance  of  provoking  abortion  by  a 
cervical  amputation  should  not  be  allowed  to  influence  us,  if 
there  is  a  probability  of  subsequent  serious  and  dangerous  inter- 
ference with  the  mechanism  of  labour.  If  the  uterus  is  other- 
wise healthy,  there  is  no  reason  why  the  operation  should  not  be 
successfully  performed  without  inducing  abortion. 

35 


546  THE  PATHOLOGY  OF  PREGNANCY 

If  the  condition  is  seen  for  the  first  time  when  the  patient 
comes  into  labour,  the  progress  of  the  case  must  be  carefully 
watched.  If  dilatation  does  not  proceed  naturally,  it  may  be 
necessary  to  attempt  to  dilate  the  cervix  artificially  by  means 
of  hydrostatic  dilators.  If  an  attempt  to  do  so  is  unsuccessful, 
the  cervix  must  be  dilated  by  means  of  deep  incisions,  as  recom- 
mended by  Diihrssen,  or  it  may  possibly  in  rare  cases  be  necessary 
to  perform  Caesarean  section.  It  is  unlikely  that  Bossi's  or 
Frommer's  dilator  would  be  of  use  in  these  cases,  owing  to  the 
alterations  in  the  cervical  tissues. 


HERNIA  OF  THE  PREGNANT  UTERUS 

'  Hernia  of  the  pregnant  uterus  is  an  extremely  rare,  condition, 
so  much  so  that  up  to  1885  only  seven  cases  of  inguinal  hernia 
were  recorded  in  medical  literature  (Eisenhart*),  about  three 
cases  of  umbilical  hernia,  and  one  of  femoral  hernia. 't 

/Etiology.  —  An  inguinal  hernia  will  in  all  probability  be 
caused  by  the  appendages  on  one  side  passing  into  the  sac  of 
a  pre-existing  inguinal  hernia  and  becoming  adherent  there, 
the  uterus  being  dragged  after  them  as  the  hernia  enlarges. 
Winckel  states j  that  a  congenital  form  of  hernia  of  the  uterus 
or  of  a  uterus  bi-cornis  or  unicornis  may  ^Occur.  He  explains 
this  by  comparison  with  the  descent  of  the  testicle  in  the  male. 
'  If  the  ovary  descends  along  the  round  ligament,  as  does  its 
analogue  the  testicle,  along  the  gubernaculum  Hunteri,  and  if, 
as  in  the  male  fcetus,  even  a  short  processus  vaginalis  of  peri- 
toneum passes  into  the  inguinal  canal,  then  the  ovary,  though 
it  has  not  yet  passed  through  the  inguinal  canal,  is  disposed  to 
enter  an  inguinal  hernia  if  the  latter  develops  later  on,  and  the 
uterus  or  the  corresponding  uterine  horn  follows  the  shortened 
round  ligament.' 

The  uterus  can  only  enter  an  umbilical  hernia  when  it  has 
sufficiently  developed  to  reach  the  opening  into  the  sac.  Ken- 
nedy §  records  a  case  in  which  the  entire  uterus  passed  into  such 
a  hernia,  and  was  found  outside  the  abdominal  cavity  hanging 
down  to  the  knees. 

Diagnosis. — The  diagnosis  will  be  made  from  the  history  of  the 
patient,  from  the  absence  of  the  uterus  from  its  proper  position, 
and  by  tracing  the  connection  between  the  tumour  contained  in 
the  hernia  and  the  cervix. 

Treatment. — The  condition  must  in  all  cases  be  relieved  as  soon 
as  it  is  recognised,  as  the  farther  pregnancy  advances  the  more 
difficult  it  will  be  to  do  so.     If  the  case  is  seen  while  the  uterus 

*   '  Em  fall  von  hernia  inguinalis,'  etc.,  I.-D. ,  Leipzig,  1885. 
•j-  Spiegelberg,    'Text-book    of    Midwifery,'    Sydenham    Society's   edition, 
vol.  i  ,  p.  381. 

X  Op.  cit.,  p.  246.  §  '  Obstetrical  Auscultation,'  p.  40. 


MALFORMATIONS  OF  THE  UTERUS  OR   VAGINA 


547 


is  still  small,  it  may  be  possible  to  reduce  the  latter  by  cutting 
down  on  the  ring,  and  if  necessary  enlarging  it.  The  opening 
should  then  be  closed  by  one  of  the  recognised  operations  for  the 
radical  cure  of  hernia.  If  the  uterus  is  too  large  to  offer  a  hope 
of  reduction,  but  the  fetus  is  not  too  large  to  pass  through  the 
opening,  abortion  may  be  induced.  If  pregnancy  is  too  far 
advanced  to  permit  even  of  this  course,  it  will  be  necessary  to 
cut  down  upon  the  uterus  and  perform  Caesarean  section.  If  the 
uterus  cannot  then  be  reduced,  it  ought  to  be  removed.  It  ought 
to  be  possible  to  replace  the  uterus  in  almost  every  case  in  which 
it  is  found  in  an  umbilical  hernia. 


MALFORMATIONS  OF  THE  UTERUS  OR  VAGINA 

The   various  malformations  of  the    uterus  which   arise  as   a 
result  of  developmental  errors  are  occasionally  of  interest  to  the 


Fig.  280. 


-Double    Uterus    and 
Vagina. 


A,  Vulva  ;  B,  urethral  orifice  ;  C,  ure- 
thra ;  D,  vagina  ;  E,  cervix  ;  F,  an- 
terior reflexion  of  peritoneum  ; 
G,  fundus;  H,  round  ligament; 
I,  Fallopian  tube  ;  K,  ovary. 
(Courty.) 


Fig.  281. — Uterus  Bi-cornis,    with 
Double  Vagina. 

A,  Vagina  ;  F,  cervix  ;  G,  fundus  ; 
H,  round  ligament ;  I,  Fallopian 
tube;  K,  ovary.     (Schrceder.) 


obstetrician,  as  in  certain  forms  they  may  give  rise  to  complica- 
tions during  pregnancy  or  labour.  The  nature  and  origin  of 
these  malformations  will  be  best  explained  by  a  brief  reference 
to  the  development  of  the  uterus. 

In  the  early  embryo,  the  female  reproductive  system  is  repre- 
sented by  two  ducts,  which  lie  at  each  side  of  the  spine.  At 
about  the  eighth  week,  the  lower  two-thirds  of  these  ducts  con- 

35~2 


548  THE  PATHOLOGY  OF  PREGNANCY 

join,  the  septum  between  them  disappears,  and  they  form  a  single 
tube.  The  upper  third  of  the  ducts  remain  distinct.  From  the 
lower  half  of  the  united  ducts  is  formed  the  vagina,  and  from  the 
upper  half  the  uterus,  while  from  the  upper  third  of  the  ducts — 
the  un- united  portion — are  formed  the  Fallopian  tubes.  Thus, 
each  Fallopian  tube,  and  its  corresponding  half  of  the  uterus  and 
vagina,  were  once  a  single  tube.  This  being  so,  we  may  expect 
to  find  errors  of  development,  the  results  of  non-fusion  or  of  in- 
complete fusion  of  the  ducts,  of  insufficient  development  of  one 
or  both  ducts,  and  of  other  anomalies  which  are  not  of  impor- 
tance from  an  obstetrical  point  of  view. 

The  principal  errors  of  development  with  which  we  are  here 
concerned  are  as  follows  : — 

(i)  The  tubes  may  remain  separate  through  their  entire  extent, 


A 

Fig.  282. — Uterus  Bicornis,  with  Single  Vagina. 

A,  Vagina;  B,  cervix;  C,  fundus;  D,  Fallopian  tube;  E,  ovary;   F,  round 

ligament. 

and   thus   a    double    uterus   and    vagina   result — uterus    duplex 
separatus  or  uterus  didelphys  and  vagina  duplex  (v.  Fig.  280). 

(2)  The  tubes  may  only  coalesce  in  the  lower  third.  In  con- 
sequence there  is  a  double  uterus— uterus  duplex  separatus  or 
uterus  didelphys — with  a  single  vagina,  in  which  the  septum 
between  the  two  tubes  may  or  may  not  persist. 

(3)  The  tubes  may  remain  separate  until  the  level  of  the  cervix 
is  reached,  below  which  they  coalesce,  and  a  uterus  bi-cornis 
result  (v.  Figs.  281  and  282).  The  septum  may  or  may  not  persist 
in  the  united  portion  and  in  the  vagina.  If  the  junction  of  the 
tubes  takes  place  higher  in  the  uterus,  the  double  character  is 
merely  shown  by  a  depression  or  notch  in  the  fundus.  To  this 
condition  the  term  uterus  cordiformis  is  applied. 

(4)  The  tubes  may  completely  unite,  but  a  septum  persist  in 
either  the  uterus  or  vagina,  or  in  both.  When  it  persists  in  the 
uterus,  a  uterus  septus  bi-locularis  results,  when  in  the  vagina, 
a  vagina  septa  (v.  Fig.  283). 


MALFORMATIONS  OF  THE  UTERUS  OR   VAGINA 


549 


(5)  Only  one  Mullerian  duct  may  develop,  the  other  remaining 
rudimentary,  and  a  uterus  unicornis  result  (v.  Fig.  284). 

Symptoms. — In  the  following  account  of  the  symptoms  and 
effect  of  the  various  uterine  malformations,  we  have  drawn  largely 
from  Spiegelberg's"  writings  on  the  subject. 

Pregnancy  has  never  been  recorded  in  the  case  of  a  uterus 
didelphys.  In  the  case  of  a  uterus  bi-cornis  with  a  single  vagina, 
twins  are  not  of  uncommon  occurrence,  though,  if  the  vagina  is 
double,  they  are  rare.  Pregnancy  is  as  a  rule  uninterrupted  and 
delivery  occurs  at  full  term.  When  only  one  horn  is  impreg- 
nated, the  other  shares  to  a  considerable  extent  in  the  hyper- 
trophy of  the  pregnant  side,  and  a  decidua  forms  in  it  which  is 
expelled  after  delivery.  If  the  vagina  is  double,  and  one  half  is 
rudimentary  and  occluded,  pregnancy  on  one  side  may  coexist 


D      ^^TWTrrav^orrr) 


Fig.  283. — Uterus  Septus  Bi-locularis. 

A,  Vagina;  B,  cavity  of  cervix;  C,  septum  ;  D,  uterine  cavity;  E,  junction 
of  uterine  cavity  and  cervix;  F,  fundus;  G,  Fallopian  tube;  H,  round 
ligament. 


with  a  haematometra  on  the  other.  In  such  cases,  abortion  as  a 
rule  occurs.  During  labour,  complications  may  occur  owing  to 
the  axis  of  the  pregnant  horn  deviating  from  the  axis  of  the 
pelvic  brim,  or  to  the  unimpregnated  horn  offering  an  obstruction 
to  the  descent  of  the  foetus  into  the  pelvis,  or  to  the  deficient 
muscular  development  of  the  pregnant  horn.  In  some  cases,  the 
unimpregnated  horn  may  be  drawn  up  above  the  brim  during 
labour,  pari  passu  with  the  progress  of  retraction,  as  sometimes 
occurs  in  the  case  of  a  myoma.  If  this  occurs,  it  will  be  palpable 
as  a  small  conical  tumour  lying  to  one  or  other  side  of  the  uterus. 
When  pregnancy  occurs  in  both  horns,  labour  may  come  on  at  a 
different  time  in  each,  according  to  the  date  at  which  impregna- 
tion took  place.     Cases  such  as  this  have  given  rise  to  the  idea  of 

*  Op.  tit.,  p.  374. 


550  THE  PATHOLOGY  OF  PREGNANCY 

superfoetation.  When  pregnancy  occurs  in  one  side  of  a  uterus 
septus,  delivery  is  as  a  rule  slow  owing  to  deficient  muscular 
development.  If  the  placenta  is  attached  to  the  septum,  severe 
post-partum  haemorrhage  may  occur,  owing  to  the  paucity  of 
muscular  fibres  in  the  placental  site.  A  septum  in  the  vagina  is 
in  most  cases  pushed  to  one  side  during  delivery.  Sometimes, 
however,  it  may  obstruct  the  descent  of  the  presenting  part,  or, 
in  the  case  of  a  pelvic  presentation,  a  leg  may  descend  at  each 
side  of  it,  and  the  foetus  thus  get  astride  of  it.  If  pregnancy 
occurs  in  the  undeveloped  horn  of  a  two-horned  uterus,  the 
course  is  identical  with  that  of  a  tubal  pregnancy. 

Diagnosis. — Many  cases  of  uterine  malformation  escape  notice 
altogether,  as  they  do  not  give  rise  to  any  symptoms,  and, 
consequently,  the  examination  necessary  to  determine  their 
presence  is  not  made.  A  uterus  bi-cornis  may  be  recognised  by 
abdominal  palpation,  when  pregnancy  has  occurred  in  both  horns 


Fig.  284. — Uterus  Unicornis. 

LH,  Developed  left  horn;  RH,  non-developed  right  horn;  RT,  LT,  right 
and  left  tubes ;  RLr,  LLr,  right  and  left  round  ligaments  ;  Ro,  Lo,  right 
and  left  ovaries. 

and  is  some  way  advanced.  There  is  a  characteristic  furrow 
running  down  the  middle  of  the  abdomen  between  the  two  horns, 
and,  if  a  contraction  is  produced  by  external  friction,  the  shape 
and  outlines  of  each  horn  become  more  distinct.  The  relations  of 
the  round  ligament  to  each  horn  can  also  be  sometimes  determined. 
The  existence  of  a  second  non-pregnant  horn  may  be  determined 
by  a  careful  bi-manual  examination  during  the  early  months  ;  later 
it  is  more  difficult  to  recognise,  as  it  probably  lies  posteriorly  to 
the  impregnated  horn.  During  labour,  it  may  again  be  possible 
to  recognise  it  if  it  is  drawn  above  the  brim.  A  vaginal  septum 
can,  as  a  rule,  be  readily  recognised,  if  an  examination  is  made 
before  the  presenting  part  has  descended  into  the  vagina. 

Treatment. — The  treatment  which  must  be  adopted  in  these 
cases  depends  on  the  nature  of  the  complications  to  which  the 
malformation  gives  rise.  Resultant  abnormal  presentations  must 
be  corrected.  Deficient  expulsive  force  must  be  supplemented  by 
the  application  of  the  forceps,  or  by  version  and  extraction. 
Post-partum  haemorrhage  must  be  checked  if  it  occurs.  Any 
intra-uterine   manipulations  which    may    be   necessary   must  be 


INFLAMMATION  OF  THE   VAGINA   AND  CERVIX  551 

performed  with  great  care  and  gentleness,  as,  owing  to  the 
defective  development  of  the  uterus,  rupture  may  be  caused  by  a 
very  slight  degree  of  force.  Vaginal  septa  must  be  divided  if 
they  offer  any  obstruction  to  delivery,  or  if  it  appears  likely  that 
they  will  be  torn  during  delivery.  Pregnancy  occurring  in  a 
rudimentary  horn  must  be  treated  exactly  as  if  it  was  a  tubal 
pregnancy,  from  which  indeed  it  will  probably  only  be  dis- 
tinguished either  during  or  subsequent  to  the  removal  of  the 
gestation  sac. 


INFLAMMATION  OF  THE  VAGINA  AND  CERVIX 

Vaginitis  and  endocervicitis  are  not  uncommon  occurrences 
during  pregnancy.  When  they  occur,  they  give  rise  to  a  more  or 
less  profuse  leucorrhcea,  with  the  other  symptoms  of  vaginitis  in 
the  non-pregnant — burning  sensations  both  in  the  vagina  and 
on  the  vulva  due  to  the  leucorrhoea,  pruritus,  and,  in  the  case  of 
endocervicitis,  a  feeling  of  weight  and  pain  in  the  pelvis. 

Aetiology. — It  is  unnecessary  here  to  enter  into  all  the  causes  of 
vaginitis  and  endocervicitis,  inasmuch  as  they  are  identical  with 
the  causes  of  that  condition  in  the  non-pregnant,  and  will  be 
found  in  works  on  gynaecology.  It  is  sufficient  to  say  that,  during 
pregnancy,  the  commonest  causes  are  gonorrhoea,  gaping  of  the 
vagina  the  result  of  former  lacerations,  and  prolapse.  Leucor- 
rhoea, consisting  of  a  purely  mucous  discharge,  the  result  of 
hyperactivity  of  the  cervical  glands,  and  in  all  probability  not 
associated  with  any  bacterial  invasion  of  the  genital  tract,  may 
also  occur  as  a  consequence  of  the  stimulation  of  the  glands, 
the  direct  result  of  pregnancy. 

Treatment.  —  Gonorrhceal  vaginitis  and  endocervicitis  can,  if 
acute,  only  be  treated  with  hot  baths,  compresses  over  the  lower 
part  of  the  abdomen,  mild,  unirritating  douches  of  boric  lotion  or 
plain  water,  and,  if  the  patient  will  submit  to  the  introduction, 
tampons  of  cotton-wool  soaked  in  glycerine  and  icthyol  or  protargol, 
or  iodoform  pencils  may  be  passed  into  the  vagina.  As  the  acute 
stage  passes  off,  applications  of  solution  of  nitrate  of  silver  (ten  per 
cent.),  of  formalin  (half  to  four  per  cent.),  or  of  protargol  (one  to 
five  per  cent.),  may  be  applied  to  the  vagina  through  a  cylindrical 
speculum.  In  simple  catarrhal  vaginitis  and  endocervicitis, 
applications  of  pyroligneous  acid  (full  strength),  or  of  sulphate  of 
copper  (five  per  cent.),  may  be  similarly  applied.  If  the  endo- 
cervicitis is  marked,  local  applications  of  pure  carbolic  acid  may 
be  applied  on  a  Playfair's  probe  to  any  erosions  and  to  the  mucous 
membrane  of  the  canal,  but  the  greatest  care  must  be  taken  that 
the  probe  is  not  in  any  way  forced  into  the  canal  or  passed 
through  the  internal  os.  If  the  probe  will  not  slip  readily  into 
the  canal,  it  should  not  be  used  at  all. 

Prognosis.  —  Any   form   of   septic   or   gonorrhoea!   vaginitis  or 


552  THE  PATHOLOGY  OF  PREGNANCY 

endocervicitis  is  a  serious  matter  at  any  time,  and  especially 
during  pregnancy,  as  the  uterus  may  readily  be  infected  subse- 
quent to  delivery.  Accordingly,  such  infections  must  always, 
when  possible,  be  cured  before  the  onset  of  labour. 


TUMOURS  OF  THE  UTERUS  AND  OVARIES 

Tumours  of  the  uterus  or  ovaries  do  not  often  interfere  with 
the  course  of  pregnancy,  although  they  frequently  give  rise  to 
difficulties  during  delivery.  If  a  tumour  reaches  a  large  size  it 
may  interfere  with  the  course  of  pregnancy  in  one  or  other  of  the 
following  ways  : — - 

(i)  By  pressing  directly  upon  the  uterus,  it  may  cause  the 
descent  of  the  latter,  and  the  protrusion  of  the  cervix  through  the 
vulva.  If  the  pressure  it  exerts  is  so  great  as  to  interfere  with 
uterine  development,  abortion  or  miscarriage  may  result. 

(2)  By  causing  increased  intra-abdominal  pressure,  it  aggra- 
vates all  disorders  of  pregnancy  which  are  the  result  of  increased 
intra-abdominal  pressure.  In  trrtff  way,  a  marked  degree,  of 
constipation,  genital  and  crural  varices,  vomiting,  urinary 
troubles,  inability  to  walk,  and  general  discomfort  may  result. 
More  rarely,  the  increased  pressure  upon  the  ureters  may  give  rise 
to  partial  or  complete  suppression  of  urine. 

(3)  By  causing  increased  intra-thoracic  pressure,  it  may  give 
rise  to  palpitations  of  the  heart,  and  if  this  condition  is  unre- 
lieved, cardiac  irregularity  followed  by  cardiac  failure  may 
supervene. 

Treatment. — The  removal  of  uterine  tumours  may  be  indicated 
during  pregnancy  for  three  reasons  : — 

(1)  Owing  to  the  severity  of  the  pressure  symptoms  to  which 
they  give  rise. 

(2)  On  account  of  their  situation,  to  avoid  their  causing  com- 
plications during  delivery,  if  they  can  be  removed  without  inter- 
fering with  the  uterus. 

(3)  If  they  are  believed  to  be  malignant,  if  they  are  undergoing 
septic  or  saprophytic  degeneration,  or  if  they  become  strangulated. 

In  the  absence  of  any  of  these  indications  for  immediate 
removal,  we  may  wait  for  full  term.  The  treatment  to  be  then 
adopted  depends  upon  the  effect  of  the  tumour  upon  the  course 
of  labour,  and  will  be  discussed  in  another  place.  Small 
pedunculated  myomata  which  project  into  the  vagina  may,  how- 
ever, be  removed  when  recognised,  as  there  is  little  or  no  danger 
of  provoking  uterine  contraction  by  so  doing.  Malignant  disease 
of  the  uterus,  as  met  with  in  pregnancy,  probably  always  affects 
the  cervix.  In  all  such  cases  in  which  there  is  a  possibility  of 
removing  the  entire  growth,  total  extirpation  of  the  uterus  should 
be  performed  as  soon  as  ever  the  condition  is  recognised.  If, 
however,  complete  removal  of  the  growth  is  obviously  impossible, 


TUMOURS  OF  THE   UTERUS  AND  OVARIES  553 

pregnancy  may  be  allowed  to  continue  till  full  term,  when,  owing 
to  the  changes  in  the  cervix,  the  result  of  the  disease,  Caesarean 
section  will  probably  be  necessary.  If  the  condition  of  the  patient 
is  such  that  there  is  little  or  no  prospect  of  her  living  to  full  term, 
her  wishes  and  those  of  her  relations  must  guide  us  as  to  whether 
Caesarean  section  is  to  be  performed  in  the  interests  of  the  foetus, 
if  the  latter  is  viable.  In  the  early  months  of  pregnancy,  when 
the  foetus  is  still  small  enough  to  pass  through  the  cancerous 
cervix,-  and  when  the  patient  or  her  friends  refuse  to  allow  a 
Caesarean  section  at  a  later  date,  abortion  should  be  induced,  as 
there  is  apparently  little  doubt  that  the  existence  of  pregnancy 
stimulates  the  growth  of  the  tumour. 

Ovarian  tumours  should,  as  a  rule,  be  removed  as  soon  as  their 
existence  is  recognised,  as  the  dangers  of  the  operation  are  less 
than  those  arising  from  the  presence  of  the  tumour.  If,  however, 
the  tumour  is  only  recognised  during  or  immediately  prior  to 
labour,  its  removal  may  be  postponed  until  the  completion  of  the 
puerperium,  unless  its  position  and  nature  are  such  as  to  prevent 
the  expulsion  of  the  foetus.  The  management  of  these  cases  will 
be  referred  to  subsequently.  The  dangers  of  ovariotomy  are  no 
greater  during  pregnancy  than  at  any  other  time,  and  the  risk 
of  a  consequent  premature  expulsion  of  the  foetus  is  not  very  great. 
It  is  usually  stated  that  pregnancy  continues  after  ovariotomy  in 
over  seventy  per  cent,  of  cases. 


CHAPTER  IV 
SPECIFIC  INFECTIOUS  DISEASES  IN  PREGNANCY 

General  Observations — Diphtheria — Enteric  Fever — Erysipelas — Influenza — 
Phthisis — Pneumonia — Relapsing  Fever  —  Scarlatina — Small-pox  —  Ty- 
phus Fever. 

The  influence  of  pregnancy  on  the  course  of  the  infective 
fevers,  and  conversely  the  effect  of  the  infective  fevers  on  the 
course  of  pregnancy,  have  received  but  scant  notice  in  English 
text-books  of  midwifery.  They  have  received  more  attention 
from  writers  on  general  medicine  or  special  articles  on  fevers, 
but  even  here  the  references  are  on  the  whole  disjointed  and 
fragmentary,  so  that  it  is  extremely  difficult  to  draw  any  general 
conclusions  from  writers  on  either  of  these  two  subjects. 

It  will  be  at  once  allowed  that  the  complication  of  any  infective 
fever  with  pregnancy  must  be  viewed  with  considerable  anxiety, 
both  as  to  the  effect  of  the  disease  on  the  course  of  the  pregnancy, 
and  to  the  effect  of  the  pregnancy  on  the  course  of  the  primary 
disease,  but,  further  than  warning  friends  of  the  possible  com- 
plications which  may  ensue,  there  is,  with  a  few  exceptions,  little 
reason  for  raising  intense  alarm.  It  may  be  also  definitely  stated 
that  the  infective  fevers,  with  the  exception  of  diphtheria  and 
erysipelas,  are  not  necessarily  associated  with  an  increased  danger  of 
'  puerperal  fever.'  If  a  patient  aborts  or  miscarries,  and  the  primary 
fever  is  complicated  by  so-called  '  puerperal  fever,'  with  its  local  or 
general  phenomena,  the  medical  man  may  assure  himself  that  he 
is  dealing  with  septic  infection,  and  must  look  for  some  cause  on 
which  to  lay  the  blame  other  than  the  specific  fever  from  which 
the  patient  suffered  before  the  uterine  sinuses  were  opened.  It 
must,  however,  be  remembered  that  in  so  far  as  several  of  the 
infective  fevers  are  associated  with  catarrh  of  mucous  membranes, 
and  that  the  discharges  from  such  a  source  may,  and  usually  do, 
teem  with  pyogenic  micro  organisms,  sp  far  these  diseases  are 
associated  with  an  increased  risk  of  septic  infection. 

If  it  is  possible  to  make  any  general  deductions  from  our 
personal  experience,  they  are  as  follows  : — 

(i)  When  fever  attacks  a  patient  during  the  early  or  the  late 
months  of  pregnancy,  the  onset  of  labour  is  more  likely  to  result 
than  when  the  attack  occurs  in  the  middle  months. 

554 


DIPHTHERIA  555 

(2)  Fevers,  in  which  the  temperature  goes  through  sudden  and 
great  variations,  are  more  likely  to  cause  premature  delivery  than 
are  those  in  which  the  temperature  gradually  attains  a  high  range. 

(3)  The  higher  the  range  of  temperature,  the  more  likely  is  the 
occurrence  of  premature  delivery. 

(4)  Where  cyanosis  is  marked  during  the  course  of  a  fever, 
premature  delivery  is  very  liable  to  take  place. 

(5)  The  effects  produced  on  the  woman  by  the  fever-poison, 
such  as  high  temperature,  delirium,  cyanosis,  etc.,  appear  to  be 
the  cause  of  abortion,  rather  than  the  fever-poison  itself.  Many 
grave  cases  of  even  the  most  serious  fevers  have  run  their  course 
without  either  causing  premature  delivery  or  the  death  of  the 
child,  and  even  where  the  former  has  occurred,  a  living  child  is 
most  frequently  born,  though  it  is  likely  to  succumb  soon. 

(6)  The  onset  of  labour  during  the  course  of  a  fever  does  not 
as  a  rule  materially  alter  such  course. 

We  shall  now  consider  the  different  fevers  seriatim. 


DIPHTHERIA 

Diphtheria  is  a  disease  of  all  ages  and  both  sexes.  One  attack 
does  not  confer  immunity  against  subsequent  infection,  nor  does 
pregnancy  appear  to  cause  any  obstacle  to  infection. 

Effect  on  Pregnancy. — When  diphtheria  is  recognised  early  and 
treated  by  its  antitoxin,  the  course  of  the  disease  is  cut  short,  and 
modified  in  such  a  manner  that  little  danger  to  the  pregnancy 
results.  If  not  thus  early  treated,  and  if  the  case  is  a  severe  one, 
with  high  temperature  and  extreme  prostration,  there  is  great 
danger,  that,  apart  from  the  risk  to  life  from  the  primary  disease, 
abortion  or  premature  delivery  may  be  brought  about  by  the 
accompanying  pyrexia.  However,  pyrexia,  though  frequently 
seen,  is  by  no  means  a  marked  feature  of  diphtheria,  and,  on  the 
contrary,  the  range  of  fever  is  usually  moderate  (ioo°  to  1010  F.). 

On  the  whole,  therefore,  it  may  be  said  that  diphtheria  does 
not  seriously  threaten  the  course  of  pregnancy.  If,  however, 
labour  occurs  during,  or  soon  after  the  disease,  very  serious 
consequences  are  liable  to  occur. 

Diphtheria  may  be  considered  to  be  a  '  putrid '  disease,  accom- 
panied as  it  is  by  putrid  ulceration  and  discharge  from  throat, 
mouth,  and  nose  —  a  discharge  not  only  carrying  diphtheria 
bacilli,  but  swarming  with  all  the  ordinary  septic  and  saprophytic 
organisms.  This  discharge,  if  brought  in  contact  with  any  other 
mucous  membrane,  as,  for  instance,  the  conjunctiva  or  the 
vaginal  or  anal  mucous  membrane,  can  set  up  in  it  with  the 
greatest  readiness  a  diphtheritic,  and,  following  that,  an  ordinary 
septic  inflammation.  It  follows,  therefore,  that,  if  delivery  occurs, 
there  is  a  serious  danger  of  puerperal  infection,  and  this  danger 
is  necessarily  greater  if  instrumental  delivery  has  to  be  adopted. 


556  THE  PATHOLOGY  OF  PREGNANCY 

A  further  danger  is  also  present.  Diphtheria  is  accompanied 
by  extreme  physical  prostration,  and  especially  by  marked 
cardiac  weakness.  It  is  also  very  liable  to  be,  and  frequently  is, 
followed  by  peripheral  neuritis,  which  may  cause  various  degrees 
of  paresis  or  actual  paralysis — either  localised  or  widespread. 
Hence,  the  danger  that,  if  delivery  comes  on  during  or  soon  after 
the  disease,  death  may  suddenly  occur  from  the  increased  strain 
placed  on  an  already  prostrate  system. 

Treatment. — The  indications  for  treatment  are  clear.  Imme- 
diately on  the  recognition  of  diphtheria  in  a  pregnant  woman, 
she  should  receive  an  initial  dose  of  4,000  units  of  antitoxin, 
2,000  units  more  should  be  given  after  twelve  hours,  and  the  latter 
dose  repeated  each  subsequent  twenty-four  hours,  until  at  least 
twenty-four  hours  have  elapsed  since  the  complete  disappearance 
of  membrane.  She  should  be  given  all  the  nourishment  she  will 
take.  There  is  no  indication  for  cutting  off  solid  food,  but  it  must 
be  light  and  easily  digested.  Stimulants  may  be  given  in  small 
quantity — two  ounces  of  whisky  in  the  day  will  be  sufficient  in  an 
ordinary  case — to  stimulate  digestion  and  circulation,  but  if  decided 
weakness  is  manifested  this  dose  rhay  be  increased.  Strychnine 
must  be  given  by  the  mouth  or  hypodermically,  if  symptoms 
of  cardiac  failure  appear.  The  function  of  the  bowel  must  be 
regularly  attended  to.  Needless  to  say,  the  most  extreme  cleanli- 
ness must  be  observed  as  regards  the  clothing,  surroundings,  and 
attendants  of  the  patient,  and  every  precaution  be  taken  to  prevent 
her  from  infecting  herself  by  her  hands.  This  danger  should  be 
explained  to  her,  and  she  should  be  warned  not  to  bring  the 
hands  into  contact  with  the  external  genitals. 

If  it  is  seen  that  delivery  is  going  to  occur,  it  is  necessary 
to  have  a  separate  obstetrical  nurse  for  the  management  of 
the  labour  and  the  puerperium.  This  nurse  must  have  nothing 
whatever  to  do  with  the  general  nursing,  which  must  be  left 
entirely  to  the  medical  nurse,  who  does  nothing  else. 

Delivery  should  be  left  as  far  as  possible  to  Nature,  but,  on  the 
first  sign  of  exhaustion,  the  forceps  must  be  applied,  and  delivery 
effected  as  rapidly  as  possible.  Every  antiseptic  precaution  must 
be  taken,  and  the  operator  ought  to  wear  rubber  gloves.  As 
regards  the  child,  it  can  hardly  be  said  that  there  is  any  special 
danger,  save  from  delay  in  labour.  Of  course,  if  the  maternal 
parts  are  infected,  the  child  is  likely  to  be  also  infected  during 
birth,  but  this  is  a  remote  contingency.  The  child  should  be 
at  once  taken  from  the  mother's  room  and  not  again  brought 
into  it,  until  it  and  the  mother  are  free  from  infection.  The  period 
of  duration  of  infection  is  probably  six  weeks,  but  it  is  variable, 
and  can  only  be  ascertained  by  examining  cultures  taken  from 
the  mother's  throat.  When  these  are  found  to  be  free  from  the 
diphtheria  bacillus,  a  thorough  disinfection  of  the  room  and  every- 
thing in  it  must  be  carried  out. 


ENTERIC  FEVER  557 


ENTERIC  FEVER 


The  opinion  of  Rokitansky  and  Niemeyer  that  pregnancy 
confers  almost  complete  immunity  from  enteric  fever,  is  not  by 
any  means  borne  out  by  our  own  experience,  which  on  this  point 
coincides  with  that  of  Murchison.  Curschmann"  does  not  con- 
sider that  immunity  is  at  all  considerable.  '  In  Hamburg,  among 
1,117  women,  38  were  pregnant — 3-4  per  cent.  .  .  .  Even  at 
those  periods  of  life  in  which  the  predisposition  to  the  disease  and 
the  chances  of  pregnancy  are  diminished,  the  figures  are  relatively 
high.'  It  has  also  been  asserted  that  lactation  confers  immunity. 
This  opinion  cannot  be  upheld  either.  Numerous  cases  of  a 
mother  in  the  early  stage  of  enteric,  suckling  her  infant,  have 
come  under  our  care  in  hospital,  and  Mooref  also  has  cited  several 
cases. 

Effects  on  Pregnancy. — In  our  experience,  the  association  of 
pregnancy  and  enteric  fever  is  much  less  serious  than  it  was 
formerly  considered  to  be.  In  an  ordinary  and  otherwise  uncom- 
plicated case,  the  course  of  the  fever  does  not  appear  to  be  in  any 
way  influenced,  and  as  a  rule  a  living  child  is  born  at  full  term. 
If  the  fever  occurs  during  the  earlier  months,  the  child  at  full-term 
birth  appears  well- nourished  and  strong;  if  during  the  later 
months,  the  child  is  smaller  than  usual,  but  otherwise  healthy. 
The  premature  expulsion  of  the  ovum  appears  to  occur  with 
much  greater  frequency  in  cases  in  which  the  fever  occurs  either 
during  the  first  four  months  or  during  the  last  two  months  of 
pregnancy. 

Curschmann's  experience  agrees  with  the  foregoing.  Of  the 
thirty-eight  women  mentioned  above,  three  went  to  term,  and 
were  delivered  during  convalescence  of  living  children,  while 
fourteen,  42^1  percent.,  were  discharged  after  recovery  from  the 
attack  of  typhoid  fever  without  interruption  of  the  pregnancy. 
Of  the  other  patients,  in  whom  abortion  or  premature  labour 
took  place,  three  died.  The  mortality  during  pregnancy  was 
therefore  7-8  per  cent. 

Dreschfeld, ;  quoting  Veniat,  states  that  in  pregnant  women  the 
mortality  was  17  per  cent.,  abortion  occurring  in  66  percent.  ;  that 
on  the  introduction  of  the  cold-bath  treatment,  it  fell  to  6  per  cent., 
with  55  per  cent,  abortions  ;  and  that  in  puerperal  women,  the 
mortality  is  nearly  50  per  cent. 

The  above  mentioned  mortality  of  17  per  cent,  in  pregnant 
women  is  slightly  less  than  the  general  percentage  mortality  for 
enteric  fever  in  the  Glasgow  Fever  Hospital  § — viz.,  17-29  per 
cent.,  whereas  the  general  mortality  for  enteric  in  Cork  Street  Fever 
Hospital,  Dublin  (1871-1890),  was  only  8*6  per  cent.     It  is  to  be 

*  '  Nothnagel's  Encycl.,'  English  ed.,  article  'Typhoid  Fever.' 

•(•  'Eruptive  and  Continued  Fevers,'  p.  402. 

J  '  Allbutt's  System  of  Medicine,'  vol.  i.,  p.  845.  §  Ibid. 


558  THE  PATHOLOGY  OF  PREGNANCY 

regretted  that  no  statistics  of  pregnancy  cases  are  available 
in  the  latter  hospital,  as  we  believe  they  would  give  a  much 
lower  percentage  both  with  regard  to  mortality  and  to  premature 
delivery  than  that  given  by  Veniat. 

The  occurrence  of  bronchitis,  so  usual  in  enteric  fever,  should 
be  looked  on  as  a  serious  menace  to  the  course  of  pregnancy,  and 
every  available  measure  should  be  employed  in  its  early  stages 
to  combat  its  advance.  As  respiration  is  accelerated  by  the  fever, 
and  is  at  the  same  time  impeded  by  increased  abdominal  pressure 
on  the  diaphragm  from  the  distended  bowels  and  the  pregnant 
uterus,  bronchitis  is  very  liable  to  extend,  and  if  it  does  so 
sufficiently  to  cause  cyanosis,  or  if  pneumonia  supervenes  with 
the  same  result,  labour  will  almost  certainly  ensue. 

When  abortion  occurs  early  in  the  disease,  a  high  range  of 
temperature  will  generally  be  found  to  be  the  determining  cause, 
consequently,  efforts  should  be  made  to  bring  the  temperature, 
even  temporarily,  down  to  a  lower  level.  This  is  perhaps  best 
attained  by  watching  the  evening  rise,  and  as  soon  as  it  reaches 
1030  F.  applying  iced  cloths  for  twenty  minutes.  Such  a  method 
appears  to  be  better  than  that  of  placing  reliance  on  any  form  of 
drug,  as,  even  if  this  attains  the  object  sought  for,  it  also  depresses 
the  patient. 

It  appears  certain  that  the  fetus  is  also  infected  by  the  fever- 
poison,  but,  as  a  rule,  it  passes  through  the  ordeal  success- 
fully, unless  prematurely  separated  from  the  mother.  The 
fetal  blood  gives  Widal's  reaction  well.  In  a  recent  case  in  Sir 
Patrick  Dun's  Hospital,  Dublin,  in  which  premature  delivery 
occurred,  the  mother's  blood,  diluted  -^  with  eight  hours'  culture 
of  B.  typhosus,  gave  a  strong  reaction.  The  fetal  blood  taken 
twenty-four  hours  after  death  from  the  right  auricle,  diluted  ^ 
with  eight  hours'  culture,  caused  clumping  in  five  minutes  (Joynt). 

Such  undoubted  authorities  as  Eberth,  Widal,*  and  Giglio,t 
have  found  the  B.  typhosus  (Eberth's)  present  in  the  blood  of 
a  fetus  suffering  from  enteric,  and  Lynch  \  has  collected  sixteen 
cases  in  which  typhoid  bacilli  have  been  isolated  from  the 
organs  of  the  fetus. 

The  very  young  infant  generally  escapes  infection,  even  when 
it  has  been  suckled  by  the  mother  during  the  early  days  of  her 
attack.  The  disease  is,  however,  less  rare  in  young  children  than 
was  formerly  supposed,  and  without  doubt  many  cases  of  in- 
fantile remittent  fever  are  really  enteric,  which  in  these  young 
subjects  usually  runs  a  mild  course  and  is  difficult  to  diagnose. 

Treatment.  —  Enteric  fever  always  causes  anxiety,  and  the 
addition  of  pregnancy  as  a  complication  must,  in  spite  of  what 
has  been  said  of  a  reassuring  nature,  greatly  increase  this. 
Remembering  the  ill  effects  which  anxiety,  trouble,  and  worry,  have 

*  Centvalbl.  fur  die  Med.  Wochensch.,  June  1,  1889. 
I  Centvalbl.  fur  Gyndkol.,  No.  46,  p.  819,  1890. 
%  Johns  Hopkins  Hospital  Bull.,  vol.  xii. 


ERYSIPELAS  559 

on  any  patient,  especially  on  those  who  have  to  go  through  a  long 
and  trying  illness  such  as  enteric,  we  must  be  doubly  on  our 
guard  against  imparting  any  of  our  fears  to  the  patient.  We  are, 
we  think,  even  justified  in  making  light  of  the  fact  of  pregnancy 
being  present,  and  should  certainly  appear  to  ignore  it  in  our  daily 
examination  of  the  patient.  In  treating  the  enteric  fever,  we 
follow  the  same  lines  as  in  the  case  of  a  non-pregnant 
patient.  We  must  recognise,  however,  the  pressing  danger  of 
bronchitis  and  high  temperature,  and  deal  with  them  as  above 
indicated.  The  friends  ought  to  be  warned  that  premature 
delivery  may  occur,  in  order  that  the  necessary  preparations  may 
be  made.  By  far  the  most  important  precautionary  measure  is 
scrupulous  cleanliness.  With  a  more  or  less  helpless  patient, 
who  passes  frequent  and  liquid  evacuations  into  a  bed-pan,  soiling 
of  the  person  and  clothing  is  prone  to  occur,  and  the  regular 
sponging  of  the  one  with  antiseptic  solutions,  and  the  frequent 
changing  of  the  other,  are  essential  to  minimise  the  risk  of  sepsis 
after  delivery. 

When  labour  does  come  on,  vaginal  examinations  must  be 
avoided  and  the  expulsion  of  the  foetus  be  left,  as  far  as  possible, 
to  the  natural  efforts,  which  are,  as  a  rule,  sufficient.  If, 
however,  the  patient  is  very  weak  from  protracted  or  severe  fever, 
or  if  labour  is  not  completed  within  a  few  hours,  delivery  must 
be  expedited  by  the  application  of  the  forceps.  Owing  perhaps 
to  the  softening  and  relaxation  of  the  maternal  passages  due 
to  the  fever,  labour  is  usually  accomplished  with  comparative 
ease  and  with  little  delay.  Too  much  care  cannot  be  devoted 
to  every  detail  in  obtaining  the  most  perfect  asepsis  possible. 
Accidents  such  as  intestinal  haemorrhage  or  perforation  do  not 
appear  to  occur  as  the  direct  outcome  of  labour.  These  accidents 
may  occasionally  occur,  but  we  have  not  known  of  such,  and  they 
have  not  been  noted  in  the  experience  of  other  writers. 

If  possible,  a  special  nurse  should  be  engaged  for  the  ob- 
stetrical nursing,  while  another  nurse  carries  out  the  general 
nursing.  This,  however,  though  very  advisable,  is  not  so  neces- 
sary as  in  other  infective  diseases. 


ERYSIPELAS 

Erysipelas  may  occur  in  the  pregnant  or  parturient  woman  as 
a  primary  local  infection,  or  secondary  to  a  general  septic  infec- 
tion. There  is  no  reason  for  supposing  that  its  primary  occur- 
rence is  more  common  in  such  women  than  in  any  others,  but, 
inasmuch  as  the  parturient  woman  is  especially  exposed  to  the 
risk  of  septic  infection,  the  occurrence  of  secondary  erysipelas 
may  be  relatively  more  common  during  the  puerperium  than  at 
other  times. 

Effect  on  Pregnancy. — Since  the  temperature  in  erysipelas,  as  a 


560  THE  PATHOLOGY  OF  PREGNANCY 

rule,  rises  suddenly,  and  is  frequently  associated  with  acute  'sthenic 
delirium,'  erysipelas  is  very  prone  to  bring  about  the  premature 
expulsion  of  the  ovum.  If  this  occurs,  or  if  erysipelas  starts 
primarily  during  the  puerperium,  the  danger  of  the  extension  of 
the  invading  bacteria  to  the  genital  organs,  and  the  consequent 
occurrence  of  a  local,  or  of  a  general,  septic  infection  is  very 
great.  Infection  of  the  newly-born  infant,  usually  through  the 
umbilicus,  is  also  prone  to  occur,  and  will  probably  prove  fatal. 

Treatment. — Precautionary  measures  are  of  the  first  importance. 
As  Felheisen  has  shown  that  the  cause  of  erysipelas  is  a  strepto- 
coccus very  closely  allied  to,  if  not  identical  with,  Streptococcus 
pyogenes,  it  is  reasonable  to  administer  at  once  hypodermically 
10  c.cs.  of  antistreptococcic  serum,  not  only  with  a  view  of  curing 
the  disease,  but  as  a  prophylactic  measure  in  the  event  of  delivery 
taking  place,  and  this  dose  should  be  repeated  daily  until  the 
symptoms  disappear.  Should  labour  come  on  during  the  disease, 
the  most  elaborate  precautions  must  be  taken  to  prevent  infec- 
tion. At  the  same  time,  it  may  be  assumed  that  infection 
will  take  place,  and  prophylactic  doses  of  antistreptococcic 
serum  should  be  continued.  *  The  prospects,  however,  are  grave 
from  the  first,  and  erysipelas  in  the  puerperal  state  is  acknow- 
ledged by  all  writers  as  almost  certainly  fatal.  Its  curative 
treatment  is  identical  with  that  of  septic  infection,  and  will  be 
discussed  subsequently. 


INFLUENZA 

The  symptoms  and  consequences  of  influenza  have  been  so 
variable  in  different  epidemics,  that  it  is  difficult  to  make  any 
general  statements  regarding  its  effects  on  pregnancy.  There 
are,  however,  certain  consequences  definitely  associated  with 
influenza,  that  must  be  regarded  as  of  extreme  gravity  when  they 
occur  during  the  pregnant  state.  These  are,  profound  mental 
depression  with  physical  weakness,  a  peculiarly  malignant  form  of 
pneumonia,  peripheral  neuritis  of  random  distribution  and  which 
sometimes  affects  vital  nerves,  and  mental  derangement.  The 
cause  of  the  last-named  is  not  difficult  to  find.  Marked  mental 
depression  is  a  frequent  occurrence  in  influenza  even  in  the 
non-pregnant,  and  serious  mental  disturbances  occasionally  occur 
during  an  apparently  normal  pregnancy.  It  is  therefore  but 
natural  to  expect  that  when  influenza  and  pregnancy  are  associated, 
the  probability  of  the  occurrence  of  insanity  is  greatly  increased. 

Pneumonia  in  influenza,  even  in  the  non-pregnant  woman,  has 
deservedly  earned  a  bad  reputation,  and  when  it  occurs  during  preg- 
nancy it  is  a  far  more  serious  condition.  In  consequence  of  the 
high  temperature  and  the  cyanosis,  it  is  most  probable  that 
premature  labour  will  result,  and  the  effect  of  this,  added  to  that 
of  the  disease,  is  highly  dangerous  to  the  life  of  the  woman. 


MEASLES  561 

If  there  is  any  extensive  manifestation  of  peripheral  neuritis, 
the  resultant  loss  of  muscular  power  further  complicates  matters. 
If  the  nerves  to  the  voluntary  muscles  alone  are  involved,  the 
prolongation  of  labour  may  be  the  only  consequence,  but,  if  the 
visceral  nerves,  and  particularly  the  cardiac  nerves,  are  also 
affected,  the  result  of  the  additional  strain  of  labour  is  very  likely 
to  cause  fatal  syncope. 

Treatment. — This  consists  in  keeping  up  the  patient's  strength 
and  spirits  from  the  first.  The  terrible  depression  which  accom- 
panies influenza  is,  we  believe,  often  increased  by  the  mere  know- 
ledge of  the  fact  that  it  is  influenza.  So  many  patients  have  had 
experience  of  its  ill  effects,  either  on  themselves  or  on  their  rela- 
tions or  friends,  that  in  some  households  its  appearance  causes 
more  alarm  than  does  any  of  the  ordinary  infectious  fevers. 
It  may  therefore  be  justifiable  to  conceal,  if  possible,  the  real 
nature  of  the  disease,  and  to  label  it  with  any  other  term  or  terms 
which  would  suit  the  symptoms.  If  labour  occurs,  it  should  be 
hastened  as  much  as  possible,  and  delivery  effected  by  the  forceps 
at  the  earliest  possible  moment.  The  use  of  an  anaesthetic  is 
usually  contra-indicated — ether  because  of  the  great  liability  to 
lung  complication,  chloroform  because  of  the  cardiac  weakness. 
If,  however,  the  heart  is  regular  and  beating  with  fair  force,  and 
there  is  a.  good  first  sound,  the  obstetrical  degree  of  chloroform 
anaesthesia  may  be  induced. 


MEASLES 

Measles  is  a  disease  of  childhood.  Between  the  first  and  fifth 
years  of  life  the  percentage  of  cases  in  which  it  occurs  is  very 
high,  and  has  been  estimated  at  47*8  per  cent.,  whereas  for  the 
whole  period  of  life  after  twenty  years  of  age  the  percentage  of 
cases  is  only  0-7.*  It  is  for  this  reason  alone  that  pregnant 
women  are  very  rarely  attacked  by  measles,  and  not,  as  has 
been  suggested,  because  pregnancy  confers  any  immunity.  We 
thoroughly  agree  with  Dawson  Williams  t  that  '  No  age,  how- 
ever advanced,  affords  protection,  and  infants  have  been  born 
with  the  rash.'  This,  however,  is  not  the  usual  teaching,  which 
is  that  there  is  a  certain  amount  of  immunity  during  the  first  five 
months  of  life.  Von  Jiirgensen  \  says  that  '  A  pregnant  woman 
who  contracts  measles  may  communicate  the  disease  to  her 
unborn  child.  The  poison  must  be  able,  therefore,  to  pass 
through  the  placenta.  About  twenty  cases  have  been  reported 
in  all.'  After  this  statement,  one  is  surprised  to  find  the  same 
writer  §  also  stating  that  '  A  partial,  temporary  immunity  is 
universally   conceded.       This   covers   the   first    five    months    of 

*  '  Nothnagel's  Encycl.,'  English  ed. ,  article  '  Measles,'  p.  237. 
+  '  Allbutt's  System,'  vol.  ii. ,  p.  in. 

%   '  Nothnagel's  Encycl.,'  English  ed. ,  article  '  Measles,'  p.  237.       §  Loc.  cit. 

36 


562  THE  PATHOLOGY  OF  PREGNANCY 

infancy.'  It  is  difficult  to  imagine  a  change  which  could  come 
over  a  child  at  the  moment  of  birth,  and  which  could  render  it 
immune  to  a  disease  to  which  it  was  previously  and  subsequently 
liable. 

In  adults  suffering  from  measles,  the  temperature  generally 
runs  up  rapidly  to  a  high  point,  1040  or  1050  F.  not  being 
uncommon  at  the  commencement  of  the  eruptive  stage.  This 
high  and  rapidly  attained  range  is  very  prone  to  bring  on  abortion 
or  premature  labour.  Later  in  the  disease,  in  addition  to  high 
fever,  bronchitis  may  supervene,  and,  if  it  is  severe  enough  to 
produce  cyanosis,  there  is  almost  a  certainty  of  the  pregnancy 
being  abruptly  terminated.  As  measles  is  often  associated  with 
septic  processes,  such  as  purulent  or  ulcerative  conjunctivitis,  septic 
sores  about  the  nares  and  mouth,  cancrum  oris,  and  noma  pudendi, 
the  risk  of  secondary  uterine  infection  occurring  in  such  cases 
is  considerable. 

Treatment. — The  treatment  chiefly  resolves  itself  into  an  attempt 
to  reduce  a  high  temperature  and  to  combat  an  attack  of  bronchitis. 
The  former  attempt  will  be  of  little  avail,  and  even  that  little  is 
but  transitory.  The  best  means  of  guarding  against  bronchitis 
is  to  keep  the  patient's  room  at  an  equable  temperature,  taking 
care  that  it  does  not  fall  during  the  night  and  early  morning 
hours.  It  is  the  variations  of  temperature,  rather  than  the  actual 
height,  that  are  dangerous  to  the  life  of  the  ovum.  If  labour 
comes  on,  the  risk  of  septic  infection  must  be  remembered,  and 
every  effort  made  to  guard  against  it. 


PHTHISIS 

Playfair  stated  very  definitely  that  '  phthisical  women  are  not 
apt  to  conceive.'  This  may  be  true  in  advanced  or  long-standing 
cases,  but  it  is  well  recognised  that  women  with  the  so-called 
tubercular  diathesis— i.e.,  of  tubercular  stock  or  with  the  con- 
stitution which  is  very  prone  or  non-resistant  to  the  invasion 
of  tubercle  bacilli  —  appear  to  be  very  prolific.  Rapid  child- 
bearing  runs  down  their  strength  so  much  that,  if  they  have  so 
far  escaped  phthisis,  they  become  extremely  prone  to  contract 
it.  This  is  borne  out  by  the  statistics  and  investigations  of 
both  Flint  and  Gaulard,  which  show  that  a  large  percentage  of 
women  become  phthisical  during  pregnancy.  It  is  further  borne 
out  by  the  fact  that  phthisis  is  more  prevalent  among  married 
than  among  unmarried  women  in  the  proportion  of  nearly 
three  to  two.*  It  is  probable,  too,  that  the  influence  of  child- 
bearing  on  phthisis  accounts  largely  for  the  sudden  increase  in 
female,  as  compared  with  male,  mortality  between  the  ages  of 
twenty  and  thirty-five. 

From  a  considerable  experience  obtained  in  the  out-patient 
*  Cf.  First  Brompton  Report — Thompson,  '  Family  Phthisis.' 


PHTHISIS  563 

department  of  Sir  Patrick  Dun's  Hospital,  Dublin,  in  a  district 
where  there  is  a  prolific  population,  it  was  impressed  upon  us 
with  increasing  force  that  in  Ireland  at  any  rate  Playfair's  dictum 
does  not  hold  good.  The  number  of  pregnant  women  who 
suffered  from  phthisis  was  considerable,  and  in  many  cases 
subsequent  pregnancies  followed  one  another  rapidly. 

Effects  on  Pregnancy. — If  a  woman  already  phthisical  becomes 
pregnant,  the  course  of  the  disease  is  as  a  rule  little  affected 
during  the  period  of  gestation,  and  if  prior  to  conception  she 
had  few  symptoms,  the  latter  are  not  markedly  increased.  If, 
on  the  other  hand,  she  had  grave  and  well-marked  symptoms, 
they  may  undergo  a  temporary  improvement,  there  may  be 
less  sweating  and  cough,  a  better  appetite,  and  a  more 
normal  range  of  temperature.  The  child  may  be  carried  to 
full  term,  and,  unless  the  disease  was  very  advanced,  may 
appear  well  -  nourished  and  healthy.  If  the  mother  survives 
the  puerperium,  and  does  not  nurse  the  child,  she  may  on  the 
earliest  opportunity  again  become  pregnant,  but,  even  in  the 
short  interval,  the  phthisical  symptoms  become  much  worse.  If 
the  mother  nurses  the  child,  these  phthisical  symptoms  usually 
manifest  themselves  in  a  still  more  aggravated  manner,  as  the 
loss  of  strength  is  more  rapid  on  account  of  the  drain  of  lactation. 
When  pregnancy  occurs,  the  constitutional  symptoms  then  abate 
somewhat,  the  lung  condition,  as  it  were,  stands  still  for  a  time, 
or  at  least  does  not  make  such  rapid  advance  as  it  had  previously 
made.  There  is  not,  however,  any  real  improvement,  as  has  often 
been  erroneously  supposed  to  occur — an  ignorant  fallacy  owing  to 
which  women  have  sometimes  been  urged  to  marriage  and  preg- 
nancy, as  a  supposed  benefit,  if  not  a  cure,  of  phthisis.  In  twenty- 
seven  cases  collected  by  Grisolle,*  the  average  duration  of  the 
disease  was  only  nine  and  a  half  months. 

As  a  rule,  the  child  is  carried  to  full  term  and  parturition  is 
normal.  If  the  phthisis  has  reached  its  final  stage,  the  patient 
will  probably  live  just  long  enough  to  bring  the  child  to  full  term 
and  give  it  birth.  Labour  is  apparently  the  last  effort  of  Nature, 
and  when  it  is  accomplished  the  mother  dies. 

It  should  be  remembered  that,  even  in  healthy  women, 
over-lactation  may  cause  symptoms  which  may  be  mistaken  for 
phthisis.  The  patients  become  weak  and  pale,  lose  flesh,  and 
develop  night-sweats,  and  if,  in  addition,  they  catch  an  ordinary 
cold,  and  are  unable  to  shake  off  a  cough,  the  diagnosis  is  difficult 
in  the  extreme.  The  proper  treatment  in  such  cases  is  to  stop 
lactation.  The  diagnosis  will  then  soon  be  cleared  up  by  the 
rapid  improvement  and  restoration  of  health.  The  effect  of 
maternal  phthisis  on  the  foetus  is  eminently  deleterious.  It  has 
been  said  above,  that  the  child  often  appears  well  nourished  and 
healthy,  but  this  remark  only  refers  to  the  first  child  after 
phthisis  has  manifested  itself,  and  to  cases  in  which  the  advance 
*  Arch   Gen.  de  Med.,  vol.  xxii. 

36—2 


564  THE  PATHOLOGY  OF  PREGNANCY 

of  the  disease  is  not  very  rapid.  If  the  infant  is  nursed,  it 
runs  the  very  serious  risk  of  maternal  infection  either  through 
the  milk,  or,  more  probably,  from  material  expelled  from  the  lungs. 
It  is  therefore  obvious  that  both  for  her  own  sake  and  that 
of  the  child,  the  mother  should  not  breast-feed  it.  The  result 
of  a  second  or  subsequent  pregnancy  is  almost  certainly  a 
weakling.  As  Gaulard  says : — '  The  children  born  of  phthisical 
mothers  are  usually  feeble,  often  at  first  become  scrofulous,  and 
subsequently  tuberculous.'  Besides  this,  premature  delivery  is 
not  uncommon  when  the  disease  is  very  acute  and  accompanied 
by  great  and  rapid  alternations  of  fever,  and  here,  again,  the 
child  is  either  born  dead  or  soon  succumbs. 

The  subject  of  transmission  of  tuberculosis  to  the  ovum  has 
been  dealt  with  in  a  previous  chapter  (Part  VI.,  Chap.,  ii.). 

Treatment. — If,  from  the  family  history  or  the  examination  of 
the  patient,  there  is  reason  to  suspect  that  she  lacks  the  normal 
power  of  resistance  to  tubercle  invasion,  she  should  be  warned 
to  avoid  repeated  pregnancies  and  prolonged  lactation.  Pincus* 
has  gone  so  far  as  to  recommend  and  to  practise  the  use  of  atmo- 
causis  in  cases  of  phthisis,  with  the  object  of  completely  destroying 
the  endometrium,  and  so  rendering  pregnancy  impossible. 

There  are  differences  of  opinion  as  to  whether  pregnancy  in 
phthisis  should  be  artificially  terminated  or  not.  The  weight  of 
opinion  seems  to  be  against  this,  in  that  it  does  no  permanent 
good.  It  may,  however,  be  indicated  as  the  only  means  by  which 
the  life  of  the  fcetus  can  be  saved. 

The  treatment  of  labour  in  phthisis  does  not  call  for  much 
discussion.  As  a  rule,  the  mother  expels  the  foetus  by  the 
natural  efforts,  but,  if  there  is  any  delay  or  if  her  strength 
fails,  the  forceps  should  be  applied  as  soon  as  possible,  and 
delivery  thus  effected. 


PNEUMONIA 

In  a  disease  such  as  pneumonia,  where  the  temperature  rises 
suddenly  to  a  high  level,  often  with  severe  rigors,  and  is 
maintained  there,  the  liability  to,  indeed  the  probability  of, 
premature  delivery  is  very  great,  even  in  the  early  days  of  the 
disease.  Again,  later  in  the  course  of  the  disease  there  is  a 
tendency  to  cyanosis,  and  an  increased  probability  of  premature 
delivery  if  that  event  has  not  already  occurred. 

Pneumonia  being  a  serious  disease  with  a  high  mortality,  it 
is  natural  that  the  latter  should  be  raised  by  the  complication 
of  pregnancy.  As  it  is  an  acute  and  '  sthenic '  disease,  one  would 
expect  the  labour  to  be  accomplished  without  artificial  aid,  and 
if  delivery  took  place  at  an  early  stage  in  the  pneumonia,  the  child 

*  Centralb.  fur  Gyntih.,  No.  8,  1902. 


RELAPSING  FEVER  565 

to  be  born  alive,  and,  if  viable,  to  survive ;  while,  if  labour 
had  been  brought  on  by  cyanosis,  one  would  expect  the  cyanosis 
to  have  probably  first  caused  the  death  of  the  child. 

These  a  priori  deductions  are  borne  out  by  the  very  few  and 
extremely  scattered  references,  that  are  to  be  found  in  contem- 
porary writings,  to  the  effect  of  pneumonia  on  pregnancy,  and 
also  by  such  cases  as  have  been  under  our  own  care.  Moore* 
considers  that  one  reason  for  the  higher  mortality  in  pneumonia 
in  women  than  in  men  is  that  the  complication  of  preg- 
nancy adds  immensely  to  the  danger,  while  Playfair  |  recorded 
fifteen  cases  collected  by  Grisolle,  of  whom  eleven  died, — a 
very  high  mortality.  The  larger  proportion  also  aborted,  the 
children  being  generally  dead. 

Treatment. — We  do  not  know  of  any  treatment  that  will 
lessen  the  risk  of  premature  delivery  in  pneumonia.  Should 
labour  come  on,  it  must  be  terminated  as  soon  as  possible, 
especially  in  the  presence  of  marked  dyspnoea,  cyanosis,  or 
symptoms  of  failing  heart,  else  both  lives  will  probably  be  lost. 
The  relief  of  abdominal  pressure,  and  the  haemorrhage  consequent 
on  labour,  appear  to  be  beneficial  in  easing  the  respiration  and 
relieving  the  engorgement  of  the  right  side  of  the  heart,  so  that 
when  labour  has  been  safely  accomplished  the  patient  is  usually 
considerably  relieved,  and  sleep — the  thing  most  frequently 
wanting,  the  most  difficult  to  obtain,  and  the  most  beneficial 
when  it  occurs — is  obtained.  The  puerperal  state  must  be 
managed  precisely  as  in  any  normal  case,  and  there  is  no  in- 
creased risk  of  sepsis.  The  pneumonic  condition  must  be  treated 
throughout  as  though  pregnancy  was  not  present.  Stimulants  will 
probably  be  required,  but  should  be  withheld  if  possible  till  the 
time  of  labour.  At  this  time,  hypodermic  injections  of  strychnine 
and  the  administration  of  digitalis  may  also  be  required  if  there 
are  any  signs  of  heart  failure,  and  oxygen  inhalations  may  be  of 
some  slight  value  in  cases  in  which  cyanosis  is  marked.  If  the 
right  side  of  the  heart  is  engorged,  venesection  to  the  extent  of 
twenty  to  thirty  ounces  gives  some  relief. 


RELAPSING  FEVER 

Relapsing  fever  is  now  such  a  rare  disease  in  these  countries 
that  its  consideration  might  here  be  dispensed  with.  It  is,  how- 
ever, interesting  to  briefly  record  its  influence  on  pregnancy,  as 
affording  strong  support  to  the  second  general  conclusion  we  have 
already  stated,  namely,  that  fevers  in  which  the  temperature  goes 
through  sudden  and  great  variations  are  more  liable  to  bring 
about  premature  delivery  than  are  those  in  which  the  temperature, 
though  high,  reaches  its  maximum  gradually.     In  the  absence  of 

*  '  Encyclopaedia  Medica,'  article  '  Pneumonia,'  p.  446. 
f  '  Science  and  Practice  of  Midwifery,'  vol.  i.,  p.  247. 


566  THE  PATHOLOGY  OF  PREGNANCY 

any  personal  experience  of  the  disease,  we  must  rely  altogether 
on  the  experience  of  Murchison,  and  on  cases  collected  by  him.  He 
considers  that  relapsing  fever  is  far  from  being  a  fatal  disease, 
and  that  as  compared  with  typhus  or  enteric  fever,  its  rate  of 
mortality  is  extremely  small,  about  1*84  per  cent.  Miscarriage 
almost  invariably  occurs,  according  to  Cormack,  most  frequently 
during  the  period  of  the  relapse.  Of  nineteen  cases  under  Jackson 
of  Leith,  twelve  aborted  during  the  first  paroxysm  ;  six  during 
the  second  ;  and  one  during  the  third.  Premature  delivery  is  the 
rule  with  exceedingly  few  exceptions.  It  is  probably  due  to 
the  very  rapid  rise  in  the  temperature,  which  within  twelve  hours 
often  runs  up  to  1040  or  1060  F.  Delivery  is  sometimes  followed 
by  copious  haemorrhage,  or  by  rapid  sinking  and  death  ;  but,  as  a 
rule,  the  mother  recovers,  although,  even  when  pregnancy  is 
advanced,  the  child  is  still-born,  or  only  survives  a  few  hours. 

Treatment. — There  does  not  appear  to  be  any  special  treatment 
of  value,  as  nothing  that  we  know  of  will  cut  short  the  disease 
or  lessen  the  risk  of  abortion.  There  is  no  special  danger  of 
septic  infection. 


SCARLATINA 

The  occurrence  of  scarlatina  during  pregnancy  is  extremely 
rare.  Amongst  the  228  cases  of  scarlatina  in  females  between 
the  ages  of  fifteen  and  forty  which  have  been  treated  in  Cork 
Street  Hospital,  Dublin,  during  the  past  four  years,  we  have 
not  seen  a  single  case  of  pregnancy,  though  cases  have  been 
admitted  in  the  puerperal  state.  Von  Jurgensen*  states  that 
the  extreme  rarity  of  scarlatina  during  pregnancy  is  generally 
accepted  as  a  fact,  while  Olshausen  j  was  only  able  to  discover 
seven  cases. 

A  partial  explanation  of  this  rarity  may  be  the  fact — which 
obtains  in  this  country  at  all  events — that  there  is  probably  no 
form  of  sickness  which  the  public  hold  in  such  dread  as  scarlatina 
in  association  with  pregnancy,  and  that  consequently  greater 
precautions  are  taken  to  avoid  infection  than  in  the  case  of  any 
other  disease.  It  is  probable  that  this  wholesome  fear  originated 
from  the  teaching  of  the  older  midwives,  who,  confusing  septicaemic 
rashes  with  scarlatina,  held  that  puerperal  women  were  extremely 
prone  to  take  infection  and  were  almost  certain  to  die. 

For  years,  a  controversy  has  raged  around  the  subject  of  so- 
called  'puerperal  scarlatina,'  which  was  supposed  to  be  prone  to 
break  out  as  an  epidemic  amongst  puerperal  women,  to  assume 
a  grave  and  toxic  form,  and  almost  invariably  to  result  in  a 
fatal  termination.  The  British  school  is  largely  responsible  for 
maintaining  the  existence  of  this  special  form  of  scarlatina,  but 

*  '  Nothnagel's  Encyclopaedia,'  English  ed.,  article  '  Scarlatina,'  p.  398. 
t  Archiv  fi'ir  Gynakologie,  1876,  vol.  ix.,  p.  188. 


SCARLATINA  567 

it  secured  some  ardent  supporters  on  the  Continent.  Olshausen 
is  one  of  these,  and  his  advocacy  led  him  to  take  up  the 
following  curious  position  : — '  We  are  impelled,'  he  says,  '  to 
the  belief  that  the  incubation  period  (of  scarlatina)  tends  to 
lengthen  itself  out  during  the  time  of  pregnancy,  and  last  months 
even,  under  certain  circumstances,  until  with  delivery  the  con- 
tagion springs  forth  into  active  eruption  '!*  Such  an  assertion 
shows  the  straits  to  which  the  supporters  of  the  existence  of 
'  puerperal  scarlatina '  are  driven,  and  the  length  they  will  go  in 
the  endeavour  to  support  their  case.  It  cannot  be  maintained, 
however,  that  the  tendency  to  scarlatina  is  in  any  way  increased 
by  the  trauma  of  delivery.  Several  typical  cases  have  come 
under  our  observation,  in  which  scarlatina  attacked  women  in 
the  puerperal  state.  The  disease  ran  a  rather  more  severe  course 
than  the  average  of  the  cases  of  scarlatina  under  observation  at 
the  same  time,  and  the  milk  was  suppressed.  There  was  no 
change  in  the  lochial  discharge  other  than  a  slight  increase  in 
its  amount.  In  each  case  the  patient  recovered,  and  the  infant 
having  been  removed  from  the  mother  when  she  became  ill,  did 
not  develop  the  disease.  On  the  other  hand,  we  have  seen  a 
considerable  number  of  cases  of  puerperal  septicaemia  in  which 
there  appeared  a  widespread  or  universal  scarlatiniform  rash,  and 
in  no  way  did  they  differ  from  non-puerperal  septicaemia  in 
which  a  similar  form  of  rash  appeared.  They  were,  in  fact, 
cases  of  general  septicaemia  occurring  in  the  puerperal  state, 
and  ran  such  a  course  as  would  be  expected  in  such  cases,  and 
not  the  course  of  scarlatina. 

We  thoroughly  agree  therefore  with  the  position  taken  up  by 
Dakin,f  when  he  says  that  scarlatinal  infection  results  in  scarla- 
tina, and  nothing  else,  in  a  puerperal  woman.  She  may  have 
septicaemia  as  well,  but  this  must  be  from  an  independent  source. 

We  do  not  propose  to  enter  into  the  arguments  for  and  against 
this  question,  but,  if  further  information  on  the  subject  is  required, 
it  will  be  found  very  fully  and  fairly  discussed  by  von  Jiirgensen.  j 

Effects  on  Pregnancy. — It  is  to  be  expected  that,  with  the  sudden 
and  severe  symptoms  which  usher  in  a  well  marked  case  of 
scarlatina,  the  course  of  pregnancy  will  be  seriously  endangered  ; 
and  so  it  appears  to  be.  Litteng  says  that  abortion  usually 
follows,  and  the  more  surely  so,  the  younger  the  state  of 
pregnancy.  Playfair||  stated  that  if  scarlet  fever  of  an  intense 
character  attacked  a  pregnant  woman,  abortion  was  likely  to 
occur,  and  that  the  risks  to  the  mother  were  very  great,  while  the 
milder  cases  ran  their  course  without  the  production  of  any 
untoward  symptoms.     Dakin  says  that  albuminuria  is  probably 

*  Olshausen,  quoted  by  von  Jiirgensen  in  '  Nothnagel's  Encyclopaedia,' 
English  ed.,  article  '  Scarlatina,'  p.  402  et  seq. 

f  '  Handbook  of  Midwifery,'  London,  1897,  p.  545. 

J  '  Nothnagel's  Encylopaedia,'  loc.  cit. 

§  Charite  Annalen,  vol.  vii.,  §  173.  il  Loc.  cit.,  i.  246. 


568  THE  PATHOLOGY  OF  PREGNANCY' 

more  constant  than  in  scarlatina  occurring  in  the  non-pregnant. 
He  also  considers  that  the  onset  of  scarlatina  in  the  later 
weeks  of  gestation  may  precipitate  labour  a  week  or  so,  and 
that  labour  is  apt  to  be  delayed  by  uterine  inertia.  The  lochia 
are  normal,  or  a  little  increased,  and  the  milk  is  diminished  or 
arrested.  He  adds  that,  in  the  new-born  child,  the  disease 
appears  soon  after  birth,  but  with  this,  however,  we  do  not  agree. 
Craiger*  believes  that  the  danger  to  life  enormously  increases 
with  the  proximity  to  the  time  of  delivery  at  which  the  symptoms 
of  the  disease  appear,  and  says  that  it  should  be  remembered 
that  the  onset  of  labour  may  be  one  of  the  invasion  symptoms 
of  the  disease  itself,  but  that  this,  however,  rarely  occurs  unless 
the  woman  has  almost  completed  her  full  term. 

The  consensus  of  opinion  may  thus  be  said  to  show  that 
in  severe  cases  there  is  great  liability  to  premature  delivery, 
and  a  serious  danger  to  the  life  of  the  mother.  The  real  danger, 
in  our  opinion,  occurs  during  the^  puerperium,  and  is  the  result, 
not  of  the  scarlatinal  infection  itself,  but  of  the  putrid  septic 
discharges  with  which  scarlatina  is  very  frequently  associated. 
Aural,  nasal,  faucial,  and  cervical  glandular  discharges — one 
or  all — may  be  present  ;  they  are  virulently  septic,  and  it  must 
never  be  forgotten  that  from  these  the  patient  may — indeed, 
is  likely  to — infect  herself.  Hence  it  is,  that  scarlatina  has  such 
a  bad  name  in  pregnant  or  puerperal  cases  ;  but  it  is  sepsis, 
not  scarlatina,  that  is  responsible,  and  it  lies  within  the  power 
of  the  medical  attendant  to  rob  these  cases  of  their  danger,  by 
taking  the  necessary  precautions  against  septic  infection. 

Treatment. — In  a  mild  case  of  scarlatina,  it  is  probable  that 
the  pregnancy  will  run  on  without  interruption.  If  the  case 
is  a  severe  one,  labour  should  be  expected  and  preparations 
made  accordingly.  If  possible,  the  family  physician  should 
insist  that  a  separate  nurse  and  doctor  are  obtained  for  attend- 
ance in  such  an  event.  The  obstetrician  should  not  attend 
another  labour  until  he  has  undergone  thorough  disinfection, 
and  has  allowed  at  least  seven  days  to  elapse.  Any  discharge 
from  the  nose  or  throat  should  be  constantly  removed  with  pieces 
of  wool  or  rag  and  immediately  burned,  the  patient  being 
warned  against  fouling  her  hands  with  these  discharges.  Any  dis- 
charge from  the  ear  or  from  a  cervical  gland  should  be  collected 
on  an  antiseptic  dressing,  which  is  kept  firmly  in  place  by  a 
bandage.  After  delivery,  especially  if  the  patient  is  delirious,  the 
hands  must  be  tied  up  in  clean  cloths,  to  prevent  them  from 
touching  the  vulva,  and  the  latter  should  also  be  protected  by 
carefully  applied  dressings.  The  urine  ought  to  be  examined 
daily  for  albumen.  If  it  is  present,  whether  late  or  early  in  the 
case,  saline  purgation  should  be  at  once  commenced.  The 
quantity  of  urine  passed  daily  must  also  be  noted,  and  any 
decided  diminution    met   by  diaphoresis.     The   best   method    of 

*  'Allbutt's  System  of  Medicine,'  ii.  147. 


SMALL-POX  569 

effecting  this  is  probably  the  hot  pack,  as  it  is  sure  in  its  action, 
does  not  weaken  the  patient,  reduces  the  temperature,  and 
usually  induces  sleep. 

Labour,  if  it  comes  on,  will  probably  be  accomplished  easily 
and  without  undue  delay.  It  is  well  to  avoid  vaginal  examina- 
tion or  interference  of  any  kind  as  much  as  possible.  If  it 
becomes  necessary  to  aid  Nature,  this  should  be  done  with  the 
most  elaborate  antiseptic  and  aseptic  precautions,  and  rubber 
gloves  must  be  worn  throughout  by  both  the  medical  man  and 
the  nurse.  As  scarlatina  patients  are  liable  to  excited  delirium, 
and  as  they  bear  sedatives  well,  a  good  sedative  draught  should 
be  given  when  the  third  stage  of  labour  is  completed,  and  the 
patient  then  left  to  as  perfect  rest  as  possible.  The  breasts  do 
not  give  trouble  during  the  fever  period,  even  if  the  pregnancy  is 
advanced,  as  the  milk  is  usually  suppressed. 


SMALL-POX 

Whether  in  its  modified  or  unmodified  form,  small-pox  has 
hitherto  been  looked  upon  as  one  of  the  most  deadly  complications 
of  pregnancy.  Up  to  the  present,  most,  if  not  all,  writers  are 
agreed  in  considering  it  a  source  of  the  very  greatest  danger  to  the 
life  of  the  pregnant  or  puerperal  woman,  and  to  the  life  of  the 
foetus  of  either  early  or  late  term.  Playfair  was  of  opinion 
that,  of  the  eruptive  fevers,  variola  has  the  most  disastrous 
results  in  pregnancy,  that  the  severe  and  confluent  forms  of 
the  disease  are  almost  certainly  fatal  to  both  the  mother  and 
the  child,  but  that  while  in  the  discrete  and  modified  form, 
abortion  frequently  results,  it  does  not  necessarily  do  so.  In 
the  Dublin  epidemics  of  1871  and  1878,  it  was  noted  that 
pregnant  and  recently-delivered  women  were  particularly  liable 
to  fatal  haemorrhagic  small -pox,  but  there  are  no  statistics 
available.  During  the  Dublin  epidemic  of  1894-1895,  a  large 
number  of  cases  of  small-pox  were  treated  in  Cork  Street  Fever 
Hospital,  and  our  recollection  tends  to  support  the  above  views. 
It  is,  however,  unfortunate  that  no  special  statistics  were  made 
concerning  pregnant  cases. 

Dr.  Ricketts,  of  Long  Reach  Hospital,  has  kindly  enabled  us 
to  give  some  observations  made  by  him  during  the  recent  epidemic 
of  small-pox  in  London  of  1901-1902.  His  conclusions  and  figures 
are  surprising  in  view  of  all  we  have  just  said,  and  are  so  interest- 
ing that  it  is  to  be  hoped  he  will  make  them  more  complete  by  a 
full  investigation  and  publication,  as  the  cases  he  deals  with  here 
'  are  only  a  fraction  of  the  total  number  treated.'  For  our  benefit, 
he  had  special  attention  paid  to  the  relation  of  small-pox  to  preg- 
nancy, in  1,500  consecutive  cases,  and,  from  the  statistics,  considers 
that  the  danger  both  to  mother  and  child  of  an  attack  of  small- 
pox complicating  pregnancy  has  been  very  generally  exaggerated. 


570  THE  PATHOLOGY  OF  PREGNANCY 

His  figures  are  as  follows  : — Of  1,500  consecutive  cases,  419  were 
adult  females,  and  of  these  30  were  pregnant.  Four  women 
aborted,  the  latest  being  at  the  seventh  month,  in  which  case  the 
child  died  immediately  ;  four  women  were  delivered  of  living 
children  at  full  term,  two  of  which  lived  and  two  died.  Three 
women  died  undelivered,  one  woman  died  after  abortion,  and  one 
woman  died  after  delivery  at  term.  From  this  it  appears  that,  of 
thirty  pregnant  women,  only  five  died  and  only  four  aborted. 
These  are  certainly  remarkable  results,  and  give  cause  for  a 
more  hopeful  view  in  such  cases  than  we  have  hitherto  been  led 
to  take. 

During  1903,  a  small  outbreak  of  small-pox  occurred  in  Dublin. 
The  cases  .were  all  treated  at  the  isolation  hospital  which  was 
placed  in  connection  with  Cork  Street  Fever  Hospital.  There 
were  123  female  patients,  of  whom  fifteen  died,  seventy  were 
between  the  ages  of  fifteen  and  fifty,  and  of  these  six  were 
pregnant.  Of  the  six  pregnant  xBases,  three  died — two  in  the 
puerperal  state  with  bad  confluent  small-pox  on  about  the  six- 
teenth day,  and  the  third  when  convalescent  from  the  disease. 
They  were  in  the  third,  sixth  and  seventh  month  of  pregnancy 
respectively,  one  child  was  born  dead  and  the  other  survived  for  two 
hours.  The  remaining  three  pregnant  cases  recovered  without  any 
interruption  to  pregnancy — of  these,  one  was  in  the  eighth  month, 
and  two  were  in  the  fourth  month  of  pregnancy.  One,  at  least, 
was  subsequently  delivered  of  a  healthy  child. 

The  foetus  in  utero  can  be  infected  by  small- pox,  and  in  some 
cases  is  born  with  cicatrices  of  the  rash,  or  with  the  actual  rash 
itself.  This,  however,  is  rare.  According  to  Ballantyne,  infants 
whose  mothers  suffered  from  small-pox  during  pregnancy  are  also 
immune  to  subsequent  infection,  even  though  they  may  have 
apparently  completely  escaped  intra-uterine  infection.  Such 
infants  are  also  usually  insusceptible  to  vaccination. 

During  the  end  of  1902,  a  large  number  of  letters  appeared 
in  the  British  Medical  Journal  on  the  effect  of  revaccina- 
tion,  during  pregnancy,  on  the  child ;  and,  though  the  experi- 
ence of  the  writers  varied,  the  correspondence  on  the  whole 
tended  distinctly  to  bear  out  the  opinion  that  the  successful 
vaccination  of  a  woman  during  pregnancy  had  a  distinct  effect 
upon  the  child.  This  effect,  however,  is  not  very  powerful,  and 
frequently  a  good  or  modified  result  is  obtained  from  subsequent 
vaccination,  though,  perhaps,  not  until  after  several  trials.  Even 
if  earlier  attempts  fail,  a  good  result  can  generally  be  obtained 
after  about  one  year.  We  hope  that  the  statistics  from  the  recent 
London  epidemic  will  be  fully  made  up  on  all  these  points,  and 
so  give  us  some  actual  data  on  which  to  found  a  judgment, 
instead  of  the  indefinite  statements  with  which  we  have  hitherto 
had  to  be  content. 

Treatment. — The  management  of  labour  during  small-pox  chiefly 
resolves  itself  into  precautions  against  septic  infection.      As  a 


SYPHILIS  571 

rule,  labour  comes  on  quickly,  and  is  accomplished  with  com- 
parative ease  and  without  undue  delay.  There  is  a  decided  risk 
of  dangerous  haemorrhage,  but  this  is  usually  foreshadowed  by 
the  haemorrhagic  character  of  the  case,  and  such  cases  are  usually 
fatal,  in  spite  of  anything  that  can  be  done.  In  non-haemor- 
rhagic  small-pox,  there  does  not  appear  to  be  any  undue  tendency 
to  post-partum  haemorrhage.  If  such  occurs,  it  must  be  dealt 
with  promptly  by  the  usual  recognised  methods.  Intra- vaginal 
manipulations  must  be  avoided  on  account  of  the  great  danger 
of  sepsis.  This  precaution  is  especially  necessary  in  the  late 
stages  of  the  disease,  as  at  this  time  boils,  or  septic  abscesses, 
all  over  the  body  are  not  uncommon,  and  the  risk  of  genital 
infection  from  their  discharge  is  very  great.  If,  however,  the 
natural  efforts  are  insufficient  to  effect  a  quick  delivery,  they 
must  be  assisted  promptly  and  rapidly,  as  in  many  cases  the 
patient's  strength  cannot  withstand  the  over-exhaustion  of  pro- 
tracted labour,  which  in  such  cases  may  be  a  greater  risk  to  life 
than  is  septic  infection. 


SYPHILIS 

The  effects  of  syphilis  in  pregnancy  are  important  and  far- 
reaching  so  far  as  the  ovum  is  concerned,  though,  as  regards  the 
mother,  they  differ  but  little  from  those  met  with  at  other  times. 
The  effect  of  syphilis  on  the  ovum  differs  considerably  according 
to  the  period  at  which  the  infection  is  contracted,  and  in  general 
it  may  be  said  that  the  nearer  the  date  of  inoculation  to  the  date 
of  conception,  the  greater  the  danger  to  the  life  of  the  ovum.  It 
is  well  known  that,  in  the  pregnant  woman,  syphilis  often  runs 
what  might  be  termed  a  benign  course.  In  1837,  Colles*  of 
Dublin  drew  attention  to  the  numerous  instances  in  which  a 
married  woman  had  no  suspicion  herself,  nor  gave  any  cause 
for  suspicion  to  her  physician,  that  she  was  syphilitic,  till  the 
birth  of  an  infected  child  gave  indisputable  evidence  of  the  fact. 

The  effect  of  the  disease,  though  it  may  not  be  manifest  in  the 
mother,  has  an  unfailing  and  profound  effect  upon  the  ovum.  In 
general,  this  is  to  cause  the  death  of  the  embryo  or  foetus,  and 
premature  expulsion  of  the  ovum,  time  after  time,  in  successive 
pregnancies.  The  typical  sequence  of  events  is  somewhat  as 
follows  : — In  her  first  pregnancy,  the  woman  aborts  about  the  3rd 
or  4th  month  ;  in  her  second  pregnancy,  she  again  aborts  about 
the  4th  month  ;  in  her  third  pregnancy,  about  the  5th  or  6th 
month  ;  in  her  fourth  pregnancy,  about  the  7th  month  ;  in  her 
fifth  pregnancy,  she  may  go  to  full  term,  but  give  birth  to  a  dead 
and  macerated  foetus ;  in  her  sixth  pregnancy,  she  may  give  birth 
to  a  living  child,  which  exhibits  signs  of  syphilis,  and  which  survives 

*  Abraham  Colles,  '  Practical  Observations  on  Venereal  Diseases,'  London 
and  Dublin,  1S37. 


572  THE  PATHOLOGY  OF  PREGNANCY 

its  birth  but  a  short  time — hours,  days,  or  weeks ;  in  her  seventh 
pregnancy,  a  living,  healthy-looking,  and  well-nourished  child  is 
born,  and  continues  apparently  in  good  health  for  a  short  period, 
it  may  be  eight  days  or  as  many  weeks,  when  unequivocal  signs  of 
the  disease  appear,  which,  if  not  properly  treated,  may  soon  prove 
fatal.  It  is  also  quite  possible  that  between  these  infected 
children,  a  child  may  be  born  in  a  healthy  condition  and  may 
remain  so.  Such  a  sequence  of  events  as  the  above  is  now  but 
seldom  met  with,  as  the  meaning  of  repeated  abortion  and  of  the 
characteristic  appearance  of  the  foetus,  are  so  well  understood  that 
the  course  of  the  disease  is  immediately  modified  by  appropriate 
treatment. 

The  effects  of  syphilis  may,  and  most  commonly  do,  differ  in 
several  particulars  from  those  just  described.  In  the  first  place, 
the  woman  frequently  manifests  the  ordinary  signs  of  syphilis,  in 
the  primary  sore  and  the  constitutional  symptoms  with  secondary 
manifestations.  Further,  the  effects  on  the  foetus  also  show  wide 
variations.  Thus,  in  some  cases,  syphilis  may  not  cause  abortion, 
and  the  mother  may  be  delivered  at  term  either  of  a  dead  child 
bearing  evident  traces  of  the  disease,  of  a  living  child  similarly 
affected,  or  of  an  apparently  healthy  child  in  whom  the  disease 
only  manifests  itself  after  some  weeks  or  months,  or  even  not  at 
all.  These  varying  effects  probably  depend  on  the  date  of  infec- 
tion relative  to  conception  and  on  the  intensity  of  the  poison.  If 
the  mother  contracts  the  disease  at  the  time  of  conception,  the 
infection  of  the  foetus  would  seem  to  be  certain ;  the  longer  the 
period  that  has  elapsed  since  the  disease  was  contracted  by  the 
mother  before  conception  takes  place,  the  better  is  the  prognosis 
for  the  child  ;  and,  if  the  mother  contracts  the  disease  at  a  late 
period  of  pregnancy,  the  child  may  entirely  escape.  If  the  mother 
develops  secondary  symptoms,  they  will  be  evident  in  such 
constitutional  disturbance  as  loss  of  flesh,  restlessness,  fever, 
anorexia,  and  pains  in  the  bones  and  joints  ;  these,  however,  vary 
greatly  in  degree  in  different  subjects,  sometimes  hardly  attracting 
attention,  in  other  cases  being  of  a  grave  and  serious  nature. 
Eruptions  and  ulcerations  of  mucous  membranes  may  also  be 
seen.  Hydramnios  is  a  very  frequent  result  of  foetal  syphilis,  so 
frequent,  indeed,  that  some  writers  have  considered  it  to  be 
pathognomonic,  a  proposition  that  cannot  be  maintained,  but 
which  serves  to  show  how  constant  is  the  association  of  the  two 
conditions.  The  premature  interruption  of  pregnancy  has  been 
already  referred  to  as  a  frequent  effect  of  syphilis ;  labour 
coming  on,  either  as  a  result  of  pathological  changes  in  the  ovum, 
or  of  the  hydramnios. 

During  labour,  the  complications  which  may  arise  as  an  in- 
direct result  of  syphilis  are  those  associated  with  the  presence 
of  hydramnios,  and  also  retained  placenta  and  post  -  partum 
haemorrhage. 

During  the  puerperium,  there  is  danger  of  septic  infection  if 


SYPHILIS  573 

there  are  chancres  or  other  form  of  local  syphilitic  eruption  about 
the  vulva,  if  the  foetus  has  died  in  utero  and  putrefied,  and  if 
fragments  of  placenta  and  membranes  are  retained. 

The  changes  in  the  ovum  that  result  from  syphilis  have  been 
already  referred  to  (Part  VI.,  Chap.  ii.). 

Treatment. — As  soon  as  the  symptoms  of  syphilis  are  recognised, 
both  parents  should  be  put  under  treatment.  In  the  early  stages, 
mercury  alone  is  indicated.  The  most  convenient  form  in  which 
to  administer  it  is  perhaps  as  a  pill,  such  as — 

ty     Hydrarg.  c.  Cretan  -         -         -         -     gr.  i. 

Pulv.  Ipecac.  Co. gr.  i. 

Ext.  Gentiani q.s. 

M. 

To  make  one  pill.     One  to  be  taken  three  times  a  day. 

This  treatment  should  be  continued  for  six,  nine,  or  twelve 
months,  unless  salivation  is  threatened,  when  the  drug  is  stopped  for 
a  time,  and  a  smart  saline  purge  is  given.  In  the  later  secondary 
stage,  iodide  of  potassium  should  also  be  given.  It  is  better  to 
combine  the  two  drugs,  as  mercury  is  always  indicated  for  the 
benefit  of  the  foetus,  and  they  may  be  given  in  mixture,  e.g.  : — 

IJ;     Liq.  Hydrarg.  Perchlor.  -  5xn- 

Potass.  Iodidi  -         -         -         -         -  -     &. 

Ext.  Sarsi  Liq.  ...  giii. 

Aquam  ad         -         -         -         -         -  -     %vi. 

M.  §ss.  ter  in  die. 

This  mixture,  though  chemically  incompatible,  is  a  recog- 
nised method  of  prescribing,  the  mercuric  iodide  formed  being 
kept  in  solution  by  the  excess  of  potassium  iodide.  Some 
writers  consider  that  in  the  case  of  a  pregnant  syphilitic 
woman  it  is  safer  to  treat  by  inunction  rather  than  by  mercury 
administered  by  the  mouth,  but  our  experience  does  not  show 
that  this  is  so.  By  adopting  anti-syphilitic  treatment  in  the  case 
of  both  parents,  not  only  miscarriage,  but  also  the  occurrence  of 
syphilis  in  the  infant  may  be  prevented. 

The  child  should  be  nursed  by  the  mother,  if  the  latter  is  able 
to  nurse,  and  on  no  account  be  given  to  a  wet-nurse.  If  it  has 
any  evidences  of  active  syphilis,  especially  of  sores  of  any  sort 
about  the  genitals,  increased  precautions  must  be  taken  that  it  does 
not  infect  any  other  person.  The  mother  herself  is  immune,  and 
comes  under  the  second  well-known  law  of  Colles*  of  Dublin, 
'  That  a  child  born  of  a  mother  who  is  without  any  obvious 
venereal  symptoms,  and  which,  without  being  exposed  to  any 
infection  subsequent  to  its  birth,  shows  this  disease  when  a  few 
weeks  old,  this  child  will  infect  the  most  healthy  nurse,  whether 
she  suckle  it  or  merely  handle  and  dress  it ;  and  yet  this  child 
is  never  known  to  infect  its  own  mother,  even  though  she  suckle 
it  while  it  has  venereal  ulcers  of  its  lips  and  tongue.' 

*  Loc.  cit. 


574  THE  PATHOLOGY  OF  PREGNANCY 

Prognosis. — In  parental  syphilitic  infection,  the  prognosis  as 
regards  the  ovum  is  very  bad,  if  special  treatment  has  not 
been  adopted.  Repeated  death  of  the  foetus  in  successive 
pregnancies  is,  as  has  been  pointed  out,  the  rule.  If  a  living 
child  is  born,  it  shows,  or  will  almost  certainly  show,  symp- 
toms of  the  disease,  which  if  they  do  not  end  fatally,  bring 
about  such  conditions  as  result  in  permanent  impairment  of  the 
health.  The  result  of  treatment  systematically  and  perseveringly 
carried  out  is  satisfactory.  Abortion  is  prevented,  the  disease  is 
arrested,  and  the  foetus,  carried  to  full  term,  is  born  in  a  healthy 
well  -  nourished  condition.  Where  treatment  is  incompletely 
carried  out,  an  apparently  healthy  child  may  be  born,  which,  in 
later  months  or  years,  shows  evidences  of  the  taint  in  snuffles, 
fissures,  badly-developed  teeth,  interstitial  keratitis,  and  such 
conditions. 


TYPHUS  -FEVER 

Typhus  fever  is  now  a  comparatively  rare  disease  in  these 
countries,  and  consequently  its  connection  with  pregnancy  is  not 
so  important  as  is  that  of  most  of  the  other  specific  fevers  with 
which  we  have  dealt.  For  this  reason,  too,  it  is  difficult  to 
speak  from  our  own  experience,  or  from  the  experience  of  others 
whose  treatment  has  been  modified  by  modern  antiseptic  practice. 

It  appears,  however,  that,  contrary  to  expectation,  the  complica- 
tion of  pregnancy  in  typhus  fever  is  not  particularly  unfavourable. 
With  such  a  grave  disease,  marked,  as  a  rule,  by  a  high  and  rapidly 
attained  range  of  temperature  and  by  severe  constitutional  symp- 
toms, one  would  expect  almost  certain  abortion,  and  probably 
maternal  death.  Such  consequences,  however,  do  not  appear  to  be 
the  case.  Murchison*  says  that  pregnancy  adds  little  to  the  danger 
of  typhus  fever,  but  that  suckling  induces  anaemia  and  increases  the 
chance  of  death  by  asthenia.  He  considers  that  pregnant  women 
are  not  exempt  from  typhus  fever ;  that  women,  even  in  an  advanced 
stage  of  pregnancy,  may  pass  through  the  disease  without  mis- 
carrying ;  and,  that  when  miscarriage  does  occur,  it  is  not  neces- 
sarily fatal  to  either  the  mother  or  the  infant.  He  collected 
1 60  cases,  of  which  71  aborted,  13  died,  and  147  recovered.  In 
seven  patients  of  his  own,  who  were  confined  during  an  attack  of 
typhus  fever  in  the  ninth  month  of  pregnancy,  two  died  of  puerperal 
fever  and  five  recovered,  while  all  the  children  were  alive  and  did 
well.  Murchison  also  points  out  that,  notwithstanding  the  sup- 
posed prejudicial  influences  of  pregnancy  and  suckling,  the 
mortality  was  less  in  females  than  among  males  at  every  period 
of  life  above  fifteen. 

These  facts  are  in  remarkable  contrast  to  those  in  connection 
with  relapsing  fever,  which  was  supposed  by  some  to  be  but  a  mild 

*  Loc.  cit. ,  p.  212. 


TYPHUS  FEVER 


575 


form  of  typhus  fever,  for  in  the  former  '  abortion  is  almost  invari- 
able and  the  foetus  dies ;  whereas  in  the  latter  abortion  is  the 
exception,  and  when  it  occurs  the  child,  if  near  full  time,  usually 
lives.' 

Treatment. — The  treatment  calls  for  little  special  remark.  Typhus 
fever  not  being  usually  accompanied  by  any  putrid  discharges, 
there  is  little,  if  any,  increased  risk  of  septic  infection.  It  is  a 
'  sthenic  '  disease,  so  that  labour  is  likely  to  be  accomplished  by 
natural  means  alone,  and  usually  with  little  delay.  Post-partum 
haemorrhage  is  said  to  occur  with  relative  frequency,  and  must 
be  treated  in  the  usual  way.  If  delay  in  labour  occurs,  there  need 
be  no  hesitation  in  applying  the  forceps. 


CHAPTER  V 
ORGANIC  AND  FUNCTIONAL  DISEASES  IN  PREGNANCY 

Acute  Yellow  Atrophy  of  the  Liver — Chorea— Diabetes  Mellitus — Nephritis — 
Cardiac  Disease  ;  Mitral  Stenosis  ;  Aortic  Regurgitation  ;  Mitral  Regur- 
gitation ;  Combined  Mitral  and  Aortic  Lesions — Hyperemesis  Gravidarum 
— Eclampsia. 

ACUTE  YELLOW  ATROPHY  OF  THE  LIVER 

This  condition  is  characterised  by  the  rapid  onset  of  illness,  which 
soon  develops  into  the  typhoid  state  with  muttering  delirium 
usually  followed  by  coma  and  death.  Moderate  jaundice  appears 
early,  and  continues  ;  vomiting  is  usual  and  the  vomit  may 
contain  blood, — bleeding  from  other  parts  may  also  occur ;  and 
fever  may  be  high  or  absent.  The  liver  is  painful  and  tender, 
and  a  daily  diminution  in  its  size  may  be  noted.  The  urine  is 
scanty,  high  coloured,  and  of  high  specific  gravity,  urea  is 
diminished  or  absent,  and  bile  pigment,  bile  acids,  and  crystals 
of  leucin  and  tyrosin  are  found  in  it.  The  average  duration  of 
the  disease  is  one  week. 

Little  is  known  of  the  cause  of  acute  yellow  atrophy.  It  is 
believed  to  be  a  toxaemia  due  to  some  micro-organism,  but  none 
has  as  yet  been  isolated.  Seventy  per  cent,  of  cases  occur  in 
women,  and  of  these  fifty  per  cent,  are  pregnant.  If  pregnant, 
the  patient  usually  miscarries. 

An  interesting  record  of  six  cases  is  given  by  Giffard  of 
Bombay.*  In  all,  the  symptoms  and  signs  were  well  marked, 
and,  in  those  in  which  a  post  mortem  examination  was  made,  the 
diagnosis  was  confirmed.  The  following  table  gives  the  important 
details  of  these  cases  : — 

*  Appendix  to  Report  of  Rotunda  Hospital,  1901-1902,  Trans.  Roy.  Acad,  of 
Medicine  in  Ireland,  1903. 

576 


CHOREA 


577 


Age. 

Preg. 

Period. 

Labour. 

State  at 
Time  of 
Labour. 

Result. 

Duration 

of 
Disease. 

Foetus. 

I. 

24 

2nd 

7th  month 

induced 

unconscious 

death  in 
2  days 

S  days 

dead 

II. 

36 

3rd 

9th      ,, 

» 

" 

death  in 
13  hours 

9 

" 

III. 

28 

3rd 

9th      „ 

accelerated 

conscious 

death  in 
2  days 

'?  4  days 

living 

IV. 

25 

2nd 

8th      ,, 

" 

comatose 

death  in 
4  hours 

? 

?dead 

V. 

26 

1st 

8th      „ 

natural 

drowsy 

death  in 
12  hours 

•> 

dead 

VI. 

18 

1st 

8th      „ 

extraction 

conscious 

death  in 
3  days 

4  days 

alive 

In  three  of  these  cases,  a  post-mortem  examination  was  made. 
In  one  case  the  liver  was  reduced  to  twenty-two  ounces  in  weight, 
in  a  second  case  to  fifty-two  ounces,  and  in  a  third  to  twenty-five 
ounces. 

Treatment. — No  special  treatment  is  known  to  have  any  beneficial 
effect.  The  only  thing  that  can  be  done  is  to  endeavour  to  main- 
tain the  patient's  strength.  Labour  should  be  induced  if  it  does 
not  come  on  spontaneously,  and  its  course  should  be  accelerated 
as  much  as  possible. 


CHOREA 


The  combination  of  chorea  and  pregnancy  is  important  from 
several  points  of  view,  and  deserves  more  attention  than  is 
usually  given  to  it.  Chorea  is  nearly  three  times  more  frequent 
among  females  than  males,  and,  among  predisposing  and  exciting 
circumstances,  menstruation,  pregnancy,  and  anaemia  are  well 
marked.  Still,  it  is  a  rare  complication  of  pregnancy.  Barnes, 
in  1868,  collected  fifty-six  cases  from  all  sources;  Fehling, 
in  1874,  collected  sixty-eight  cases  ;  Charpentier  found  only 
two  cases  out  of  1,600  deliveries  at  the  Clinique  ;  and,  in 
the  Rotunda  Hospital  statistics,  no  case  is  noted  in  20,000 
deliveries.  A  considerable  proportion  of  cases  occurring  in 
pregnancy  have  a  clear  history  of  a  previous  attack.  Fifteen 
out  of  the  fifty-six  cases  quoted  by  Barnes*  have  this  history 
definitely  noted,  and  in  several  others  there  is  no  report  to 
indicate  whether  there  had  been  a  former  attack  or  not.  All 
observers  who  have  inquired  into  the  subject  are  agreed  that 
chorea  occurring  in  early  life  has  a  strong  tendency  to  reappear 
in  pregnancy,  though  fortunately  it  does  not  always  do  so.  When 
it  does,  it  appears  in  the  great  majority  of  cases  in  the  first 
pregnancy,  but  has  been  delayed  to  the  second  or  even  to  the 


Obstet.  Trans.  Lond.,  vol.  x. 


37 


578  THE  PATHOLOGY  OF  PREGNANCY 

third.  Chorea  may  also  occur  for  the  first  time  during  pregnancy. 
It  does  not  necessarily  reappear  in  successive  pregnancies,  though  it 
sometimes  recurs  in  some  or  in  each  of  the  succeeding  pregnancies. 
In  no  small  proportion  of  cases  (10  out  of  56 — Barnes),  it  has  ceased 
during  the  course  of  pregnancy,  but,  as  a  rule,  it  continues  till 
delivery.  It  may  then  cease  with  the  pregnancy,  or  may  continue 
for  an  indefinite  time  after.  Very  rarely  (2  cases  out  of  58 — 
Barnes)  it  comes  on  just  after  delivery. 

The  death  of  the  mother  as  a  direct  result  of  the  chorea  is 
sufficiently  frequent  to  place  the  disease  amongst  the  very  serious 
complications  of  pregnancy.  Barnes  found  seventeen  deaths  in 
fifty-six  cases ;  Spiegelberg  found  twenty-three  deaths  in  eighty- 
four  cases  ;  and  Wenzel  places  the  mortality  at  27*3  per  cent. 
Abortion  or  premature  labour  is  also  common,  and  occurred  in 
eighteen  out  of  fifty-six  cases.  As  the  expulsion  of  the  ovum 
most  frequently  occurred  before  the  child  became  viable,  or,  when 
viable,  after  its  death,  it  will  be  seen  that  the  foetal  mortality 
is  also  exceedingly  high.  In  view  of  the  fact  that  the  maternal 
mortality  is  much  higher  than  the  mortality  that  obtains  amongst 
non-pregnant  cases  of  chorea,  Buist*  has  pointed  out  that,  in  a 
considerable  number  of  cases,  death  was  due  to  associated  condi- 
tions such  as  eclampsia  and  sepsis.  Nevertheless,  if  chorea  predis- 
poses to  such  associated  conditions,  its  gravity  remains. 

As  has  been  already  mentioned,  the  foetus  often  dies  in  utero, 
and  is  thus  a  cause  of  premature  labour.  It  may,  however,  reach 
full  term,  and  is  then  often  well  developed  and  healthy,  but  it 
may,  on  the  other  hand,  be  weakly  and  ill-nourished,  and  so 
may  not  long  survive  its  birth.  In  a  few  cases,  the  child  has 
been  known  to  develop  chorea  early  in  childhood,  and  in  one 
case  was  born  with  choreiform  movements  which  persisted 
throughout  life  (Mayo). 

Chorea  most  frequently  makes  its  appearance  during  the  first 
half  of  pregnancy,  most  commonly  about  the  third  or  fourth 
month.  Of  fifty-seven  cases,  twenty-two  began  during  the  first 
three  months,  twenty-three  during  the  second  three  months, 
and  only  twelve  in  the  last  three  months.  On  the  whole,  the 
pregnant  condition  appears  to  aggravate  chorea.  In  some  cases, 
no  doubt,  the  symptoms  remain  mild  throughout,  and,  as  has 
been  mentioned,  may  even  disappear,  but,  in  the  majority  of 
cases,  the  symptoms  appear  to  be  much  more  severe  than 
in  a  corresponding  proportion  of  ordinary  non-pregnant  cases. 
The  movements  are  frequently  so  continuous  that  the  patient 
is  worn  out  for  want  of  sleep  and  prostrated  from  sheer  muscular 
exhaustion,  and  they  may  be  so  violent  that  she  falls  out  of  bed, 
unless  she  is  constantly  held  down.  Speech  and  even  deglutition 
may  be  interfered  with  by  spasm  of  the  muscles  about  the  mouth 
and  pharynx,  and  respiration  may  be  so  erratic  and  spasmodic 
that  cyanosis  is  produced.  In  the  worst  type  of  case,  the  mind 
*  '  Chorea  in  Pregnancy,'  Edin.  Obstet.  Trans.,  1894-5. 


CHOREA 


579 


becomes  dull,  delirium  comes  on,  and  coma  follows.  In  some 
cases,  mania  or  other  form  of  mental  disorder  develops  during  the 
progress  of  the  case,  and  this  condition  may  persist  after  delivery 
or  may  be  recovered  from  when  the  pregnancy  or  the  chorea 
terminates,  or,  on  the  other  hand,  may  cause  a  fatal  termination. 

Chorea  has  a  distinct  tendency  to  provoke  labour.  This  may 
be  explained  by  the  profound  disturbance  of  the  nervous  system 
which  it  causes ;  by  interference  with  the  functions  of  the  body, 
and,  amongst  these,  with  that  of  respiration,  as  the  proper  aeration 
of  the  blood  is  prevented,  and  the  latter  also  becomes  overloaded 
with  carbonic  acid  from  the  increased  muscular  action  ;  and  by 
the  general  impairment  of  nutrition  following  these  conditions. 

The  condition  of  the  urine  in  chorea  is  similar  to  that  with  which 
we  are  familiar  in  febrile  states.  It  has  a  deep  colour  and  heavy 
odour,  a  high  specific  gravity,  and  there  is  great  deposit  of 
urates.  Later,  it  may  become  alkaline  with  a  considerable  excess 
of  phosphates  and  urea.  Todd,  Beale,  and  Bence  Jones  made 
special  researches  into  the  urine  in  chorea,  but,  further  than  estab- 
lishing that  the  above  conditions  were  the  rule,  and  that  the 
occasional  appearance  of  albumin  and  sugar  had  no  direct  rela- 
tion to  the  chorea,  they  found  no  definite  characters  peculiar  to 
the  disease,  or  throwing  any  light  on  its  origin. 

Treatment. — The  treatment  of  these  cases  should  aim  at  the 
very  outset  at  curing  the  chorea.  For  this,  rest  and  freedom 
from  anxiety  are  essential.  The  administration  of  iron,  zinc, 
strychnia,  or  bromide  of  potassium  has  been  recommended,  but 
the  best  results  are  perhaps  obtained  from  arsenic,  beginning 
with  a  small  dose — three  minims  of  Fowler's  solution  well 
diluted,  and  rapidly  increasing  it  up  to  ten  minims,  or  even 
more,  three  times  a  day,  after  food.  As  soon  as  itching  of  the 
eyelids  or  diarrhoea  appear,  no  further  increase  is  made,  and,  if 
these  symptoms  increase,  the  dose  must  be  reduced  or  even 
the  drug  stopped  for  a  time.  The  drug  should,  however,  be 
given  as  continuously  as  possible  until  the  symptoms  abate,  when 
the  amount  is  gradually  reduced.  If  the  case  is  severe  and  will 
not  yield  to  drugs,  it  may  be  necessary  at  times  to  use  chloro- 
form to  give  the  patient  some  rest  from  the  continuous  and 
violent  movements.  Opium,  morphia,  and  other  sedatives 
have  been  frequently  tried,  but  with  disappointing  results. 
Even  after  chloroform,  it  has  been  sometimes  observed  that 
the  movements  come  on  with  much  greater  vigour  than  before,  as 
soon  as  the  effect  of  the  drug  has  passed  off.  Digital  or  mechani- 
cal dilatation  of  the  os,  may  perhaps  be  tried,  as,  in  a  case  related 
by  Wade,  digital  dilatation  of  the  os  cured  the  chorea,  without 
interrupting  the  pregnancy,  which  continued  to  term. 

In  these  cases,  one  must  be  on  the  alert  for  any  signs  of 
threatening  mental  impairment  or  mania,  for  any  indication  that 
the  strength  of  the  patient  is  failing,  or  for  evidence  that  the 
convulsions  are  increasing  in  frequency  and  force.     Under  such 

37—2 


580  THE  PATHOLOGY  OF  PREGNANCY 

circumstances,  the  induction  of  premature  labour  is  indicated.  It 
is  remarkable  how  rapidly  grave  symptoms  come  on,  and,  as  the 
induction  of  labour  takes  some  little  time,  it  is  well  not  to  postpone 
active  treatment  until  the  last  moment,  as  it  may  then  be  too 
late  to  save  the  patient's  life.  Induction  of  labour  does  not 
always  bring  about  the  termination  of  the  chorea,  but  it  most 
frequently  does  so,  and  in  such  cases  the  prognosis  is  good.  If, 
on  the  other  hand,  the  symptoms  continue  after  labour,  the 
prognosis  is  unfavourable.  The  best  method  of  induction  is 
that  which  involves  the  least  irritation  and  disturbance  of  the 
patient,  and  leaves  labour  as  much  as  possible  to  Nature.  For 
this  reason,  Krauze's  method  of  inducing  labour  by  passing  an 
elastic  bougie  between  the  membranes  and  the  uterine  wall,  is 
perhaps  the  most  suitable.  Once  labour  has  set  in,  and  the 
uterine  orifice  has  become  fully  dilated,  there  is  usually  no  delay 
nor  further  trouble,  the  child  being  as  a  rule  expelled  by  the 
natural  efforts.  Should  there,  however,  be  any  delay,  or  appear- 
ance of  exhaustion  on  the  part  of  the  mother,  labour  should  be 
completed  as  rapidly  as  possible  by  the  forceps.  Owing  to  the 
choreic  movements,  considerable  difficulty  may  be  experienced  in 
any  necessary  manipulations.  Chloroform,  however,  is  well  borne, 
and  should  be  pushed  far  enough  to  keep  the  patient  quiet. 


DIABETES  MELLITUS 

It  is  well  known,  since  the  researches  of  Blot*  in  1856,  that 
towards  the  end  of  pregnancy  and  during  lactation,  a  small 
quantity  of  sugar  can  generally  be  easily  found  in  the  urine  ;  this 
has  been  called  galactosuria  or  resorption-diabetes.  It  is  not 
considered  a  disease  or  an  abnormal  condition,  and  must  not  be 
confounded  with  true  diabetes,  to  which  alone  we  at  present 
refer.  Matthews  Duncan  stated  that  in  the  Edinburgh  Maternity, 
when  verifying  the  French  researches,  he  had  found  traces  of 
sugar  in  the  urine  of  every  nursing  woman,  and  that  it  was  a 
natural  physiological  condition  which  had  not  been  shown  to  have 
any  relation  to  the  disease  diabetes. 

The  occurrence  of  diabetes  in  pregnancy  is  rare.  In  the  first 
place,  the  disease  is  not  a  very  common  one  ;  and  in  the  second 
place,  the  debility  caused  by  it  is  usually  so  great,  that,  as  a  rule, 
the  sexual  functions,  including  menstruation,  are  arrested.  It 
is  known  that  in  the  male,  at  least,  sexual  power  is,  as  a  rule, 
early  lost,  and  it  is  probable  that  a  similar  consequence  also  occurs 
in  the  female.  There  are  notable  instances,  however,  which 
prove  the  retention  of  sexual  potence.  Seegen  mentions  that  he 
has  seen  regular  menstruation  up  till  death  in  cases  of  severe 
diabetes,  and  several  cases  are  on  record  of  diabetic  women 
having  had  successive  pregnancies  without  any  interruption  of 
*  Gazette  des  Hopitaux,  1856. 


DIABETES  MELLITUS  581 

the  disease.  It  is  therefore  probable  that  the  combination  is  not 
quite  so  rare  as  it  has  been  considered  to  be.  It  is  remarkable 
how  little  attention  has  been  drawn  to  it  in  text-books,  journals, 
or  hospital  reports,  and  it  is  quite  possible  that  cases  escape 
detection  because  they  are  not  looked  for.  Frerichs  says  that 
of  386  diabetics  under  his  own  care,  104  were  females,  and,  of 
these,  only  one  was  pregnant.  Griesinger  found  only  two  pregnant 
cases  amongst  fifty-three  female  diabetics.  Stengel*  has  recently 
collected  from  all  sources  nineteen  cases,  amongst  which  twenty- 
seven  pregnancies  attended  with  diabetic  symptoms  occurred. 

The  recorded  cases  show  that  pregnancy  may  occur  in  a 
diabetic  woman,  or  that  diabetes  may  commence  during  preg- 
nancy, and  continue.  Diabetes  may  also  occur  only  during  preg- 
nancy, as  in  the  remarkable  case  recorded  by  Bennewitz,  in  which 
a  woman,  aged  twenty,  was  diabetic  only  while  pregnant,  and  at 
other  times  was  healthy ;  or,  on  the  other  hand,  after  the  cure 
of  diabetes,  pregnancy  may  take  place  without  the  recurrence  of 
the  disease.  From  Stengel's  investigation  of  nineteen  collected 
cases,  it  would  appear  that,  when  diabetes  complicates  pregnancy, 
it  is  usually  in  the  case  of  a  multipara,  as  only  three  of  these 
patients  were  primiparae. 

Diabetes  is  undoubtedly  a  very  grave  complication  of  pregnancy, 
maternal  death  having  occurred  at  the  time  of  labour,  or  within 
a  few  weeks,  in  ten  out  of  nineteen  cases.  Abortion  occurred 
in  six  of  the  twenty-seven  pregnancies,  and  in  eight  the  foetus  was 
born  dead  or  died  shortly  after  birth.  The  child  is  often  of  very 
large  size,  this  sometimes  being  due  to  anasarca,  and  in  one  case 
it  was  born  with  diabetes.  Hydramnios  is  common,  and  sugar 
has  been  found  in  the  amniotic  fluid.  Death  may  occur  soon  after 
the  onset  of  labour,  or,  more  commonly,  very  soon  after  delivery. 
It  is  usually  due  to  coma,  probably  induced  by  the  anxiety  and 
fatigue  of  labour.  Sometimes,  though  much  more  rarely,  death 
occurs  suddenly  from  collapse,  or  cardiac  syncope,  or  from  an 
associated  phthisis.  Seegen  records  the  case  of  a  patient  who, 
during  the  continuance  of  diabetes,  conceived  three  times,  and 
always  miscarried  about  the  middle  of  pregnancy — dying  at  the  last 
miscarriage.  Pregnancy  may  continue  to  term,  but  the  onset  of 
premature  labour  is  the  rule,  probably  due  to  the  death  of  the 
foetus. 

Treatment. — The  general  treatment  of  these  cases  is  similar 
to  that  of  diabetes  occurring  in  non-pregnant  women,  and  should 
be  careful  and  unremitting,  special  care  being  taken  ihat  the 
patient  is  not  subjected  to  mental  worry,  and  is  not  allowed 
to  undergo  fatigue  of  any  kind.  Apparently,  from  the  cases 
recorded,  no  fixed  rule  can  be  laid  down  as  to  the  treatment 
of  the  pregnancy.  As  we  have  said,  the  latter  may  terminate  nor- 
mally both  for  mother  and  child,  or  it  may  terminate  fatally  for 
the  child  without  any  warning  and  without  any  ill  effect  on  the 
*   Univ.  of  Pennsylvania  Med.  Bulletin,  October,  1903. 


582  THE  PATHOLOGY  OF  PREGNANCY 

mother.  It  may  sometimes  be  necessary  to  induce  premature 
labour,  either  for  the  sake  of  the  mother  or  of  the  child,  but 
the  indications  are  not  plain,  and  the  result  is  not  promising. 
Schauta*  considers  that,  in  diabetes,  pregnancy  ought  to  be 
interrupted,  on  account  of  the  high  rate  of  mortality  in  both 
mother  and  child,  but  as  he  appears  to  favour  this  line  of  treat- 
ment for  so  many  complications  of  pregnancy,  one  is  inclined  to 
discount  his  recommendation.  In  a  case  recorded  by  Matthews 
Duncan  premature  labour  was  induced  on  the  sudden  appearance 
of  alarming  symptoms  of  maternal  collapse,  but  the  child  was 
born  dead  and  macerated,  and  the  operation  did  not  save  the 
mother.  Labour  may  be  induced  for  the  sake  of  the  child,  either 
on  account  of  the  impending  death  of  the  mother,  or  when  the 
experience  of  former  pregnancies  showed  that  the  child,  though 
reaching  a  viable  age,  died  before  labour  came  on. 

In  the  management  of  labour  itself,  undue  delay  must  be 
avoided,  and  if  little  progress  is  being  made,  delivery  should  be 
hastened  either  by  turning  or  by  the  application  of  the  forceps. 
As  a  rule,  however,  labour  is  easy  and  not  prolonged.  A  moderate 
degree  of  chloroform  anaesthesia  is  not  contra-indicated.  During 
the  progress  of  the  case,  it  is  necessary  to  remember  that  a  large 
amount  of  urine  is  being  excreted,  and  that  the  bladder  will 
require  to  be  frequently  emptied,  if  necessary  with  a  catheter. 
The  medical  attendant  must  also  remember  that  the  onset  of 
coma  may  occur  in  some  cases. 


NEPHRITIS 

The  relation  of  nephritis  to  pregnancy  has  received  more 
attention  from  obstetricians  than  any  other  subject  of  general 
medicine,  on  account  of  the  connection  of  this  disease  with 
eclampsia.  As  the  milder  degrees  of  nephritis  are  only  recognised 
by  the  presence  of  albuminuria,  we  must  discuss  the  subject 
under  this  symptom,  irrespective  of  the  fact  that  it  is  possible  to 
have  albumin  in  the  urine,  without  any  definite  inflammatory 
change  (nephritis)  in  the  kidney. 

Frequency. — There  is  such  a  wide  difference  of  opinion  amongst 
observers  as  to  the  frequency  of  albuminuria  in  pregnancy, 
that  one  can  only  suppose  that  there  is  a  difference  in  the 
standard  taken  as  to  the  amount  or  persistence  of  albumen  that  is 
considered  pathological,  or  to  the  method  of  testing  employed. 
Dumas,  from  an  examination  of  the  statistics  of  several  observers, 
considers  that  albuminuria  occurs  in  one  out  of  every  five  or  six 
pregnant  women,  Gillette  in  thirty  per  cent.,  Barker  in  four  per 
cent.,  and  Parvin  in  six  per  cent,  of  cases.  Albuminuria  is  very 
frequently  met  with  in  twin  pregnancies.     It  is  more  frequent  in 

*  Report  Fourth  Internat.  Cong.  Gynaecol.,  1902. 


NEPFIRITIS  583 

primipara;  than  multipara?,   and  more  common  in  the  late  than 
in  the  early  months  of  pregnancy. 

/Etiology. — A  woman,  the  subject  of  chronic  nephritis,  may 
become  pregnant,  or  a  pregnant  woman  may  become  the  subject 
of  ordinary  acute  nephritis  from  any  of  the  usual  causes  of  that 
condition.  Other  cases  also  occur  which  require  a  different 
classification,  and  amongst  these  two  forms  of  renal  disease 
are  recognised: — (1)  The  kidney  of  pregnancy  (Leyden)  charac- 
terised by  the  symptoms  of  sub-acute  nephritis  coming  on  in  the 
later  months  of  pregnancy,  persisting  throughout  it,  and  usually 
passing  off  after  delivery,  not  to  recur ;  and  (2)  the  relapsing 
kidney  of  pregnancy,  in  which  albumin  and  casts  are  found 
from  the  early  months  of  pregnancy,  disappear  after  delivery  and 
return  with  each  subsequent  pregnancy.  Several  theories  have 
been  brought  forward  to  account  for  these  conditions,  and  of  these 
the  following  are  the  most  important : — 

(1)  The  increased  work  thrown  upon  the  kidneys  by  pregnancy, 
associated  with  a  direct  irritation  or  inflammation  of  the  kidney, 
the  result  of  an  altered  condition  and  greater  impurity  of  the  blood. 

(2)  Pressure  on  the  renal  veins  by  the  enlarged  uterus  and 
consequent  venous  congestion  of  the  kidneys  —  a  condition 
analogous  to  the  congestive  albuminuria  of  cardiac  disease. 

(3)  Pressure  of  the  uterus  on  the  ureters. 

(4)  Anaemia  of  the  kidney  caused  by  spasm  of  the  renal  vessels 
produced  reflexly  by  stimuli  from  the  genital  organs  (Diihrssen 
and  Spiegelberg). 

(5)  Anaemia  of  the  kidney  due  to  blocking  of  the  renal  vessels 
by  minute  emboli,  either  resulting  from  some  ferment  in  the  blood 
which  causes  coaguli  to  form,  or  coming  from  the  placenta. 

Pathological  Changes. — In  ordinary  acute  or  chronic  nephritis 
occurring  during  pregnancy,  the  histological  changes  in  the 
kidneys  do  not  differ  in  any  way  from  the  changes  that  occur  in 
the  non-pregnant  state.  In  the  kidney  of  pregnancy,  the  organ  is 
enlarged,  and  pale ;  the  capsule  strips  readily,  but  small  particles 
of  renal  substance  adhere  to  it ;  the  cortex  is  swollen  and  anaemic; 
and  the  medullary  portion  is  often  congested.  The  epithelium 
of  the  tubes  becomes  swollen,  granular,  and  shows  fatty  degenera- 
tion ;  there  is  very  frequently  an  infiltration  of  small  round  cells 
about  the  glomeruli,  particularly  around  the  '  neck,'  where  the 
vessels  enter ;  and,  when  this  is  present,  desquamation  of  the  glome- 
rular epithelium  is  seen.  Here  and  there  in  the  connective  tissue, 
a  similar  infiltration  of  small  round  cells  is  seen,  which  press  on 
the  blood  vessels. 

Symptoms. — The  symptoms  are  those  of  Bright's  disease  varying 
in  degree — namely,  probable  anasarca,  albuminuria,  tube  casts  in 
the  urine,  and  a  probable  change  from  the  normal  in  the  quantity 
of  urine  passed.  In  very  chronic  nephritis,  the  quantity  is  usually 
increased,  but  more  frequently,  as  in  sub-acute  or  acute  nephritis, 
or  in  the  nephritis  of  pregnancy,  the  urine  will  be  found  to  be 


584  THE  PATHOLOGY  OF  PREGNANCY 

diminished.  In  chronic  cases,  there  is  cardiac  hypertrophy 
with  high  tension  pulse.  Nephritis  is  decidedly  aggravated  by 
pregnancy,  and  so  all  its  symptoms  become  more  marked. 
Thus,  a  local  oedema  may  go  on  to  a  general  anasarca,  with 
effusion  into  the  serous  cavities ;  the  urine  tends  to  diminish 
steadily  in  quantity,  with  increase  of  albumin,  higher  specific 
gravity,  and  diminution  in  the  total  quantity  of  urea ;  the  diges- 
tion becomes  disordered,  and  headache  and  vomiting  (early  uraemic 
symptoms),  weakness  and  inability  to  exercise,  disturbance 
of  vision — dimness  or  amaurosis,  and  drowsiness  and  mental 
obscuration  may  occur  ;  and,  finally,  twitchings  of  muscles  or 
limbs,  going  on  to  actual  convulsions,  and  ending  in  coma 
and  death.  During  some  stage  in  this  sequence  of  events, 
it  is  probable  that  the  pregnancy  will  terminate  prematurely, 
usually  preceded  or  accompanied  by  the  death  of  the  foetus. 
Of  these  symptoms,  the  most  important,  from  a  prognostic 
point  of  view,  are  the  steady  diminution  in  the  quantity  of  the 
urine,  and  the  eye  symptoms.  Both  eyes  are,  as  a  rule,  affected, 
although  often  not  equally  so ;  vision  is  much  lowered,  and  even 
perception  of  light  may  be  wanting.  '  Blindness  is  not  always  due 
to  organic  changes  in  the  retina,  and  is  often  largely  the  result  of 
uraemia '  (Swanzy).  The  changes  seen  with  the  ophthalmoscope 
are,  venous  hyperemia,  swelling  of  the  papilla  and  of  the  retina 
in  its  neighbourhood,  haemorrhages  into  the  retina,  and  white 
spots  in  a  zone  around  the  papilla. 

Eclampsia  is  not  specially  liable  to  occur  in  true  Bright's  disease, 
a  fact  which  has  given  observers  cause  to  seek  for  some  other 
explanation  than  renal  disease  for  this  serious  condition,  but  is 
more  commonly  found  in  association  with  the  kidney  of  pregnancy. 
The  opinion  is  held  more  generally  now  than  formerly,  that 
the  nephritis  is  not  the  cause  of  the  eclampsia,  but  that  both 
nephritis  and  eclampsia  are  merely  the  expression  of  some  existing 
intoxication.  The  condition  of  the  kidneys  is  important,  however, 
in  that,  by  an  examination  of  the  urine,  its  quality,  amount, 
specific  gravity,  and  sediment,  we  have  a  tolerably  reliable 
method  of  estimating  the  danger  of  the  onset  of  eclampsia. 

In  the  so-called  relapsing  kidney  of  pregnancy,  the  symptoms 
closely  resemble  those  of  acute  Bright's  disease.  They  come  on 
early  in  pregnancy,  continue  throughout  it,  and  disappear  when  it 
terminates,  to  re-appear  in  each  succeeding  pregnancy.  The  foetus 
usually  dies,  and  eclampsia  is  rare,  though  urgent  symptoms 
may  arise,  as  in  other  forms  of  nephritis. 

Treatment. — The  routine  examination  of  the  urine  in  every  case 
of  pregnancy  should  be  carried  out  as  soon  as  the  patient  comes 
under  observation.  If  albuminuria  is  found,  treatment  should 
be  adopted  at  once,  and  continued  either  until  the  urine  remains 
free  from  albumin — a  rare  but  possible  event,  or  until  the  case 
passes  out  of  the  obstetrician's  hands.  If  there  is  no  symptom 
of  nephritis  other  than  albuminuria,  it  will  be  sufficient  to  advise 


NEPHRITIS  585 

that  the  dietary  should  consist  of  light  food  with  very  little  meat, 
except  that  of  fowl  and  fish,  once  daily,  no  soups  nor  meat  extracts, 
nor  alcohol.  The  bowels  should  act  at  least  once  a  day,  other- 
wise a  simple  purgative,  such  as  a  compound  rhubarb  pill  or 
a  drachm  of  the  liquid  extract  of  cascara  sagrada,  should  be 
taken. 

When,  from  previous  experience  of  the  patient,  we  expect  that 
nephritis  will  come  on  as  the  period  of  pregnancy  advances,  more 
rigid  prophylaxis  should  be  employed,  the  diet  being  practically 
restricted  to  milk  and  farinaceous  foods,  and  the  bowels  not  only 
made  to  act  daily,  but  purged  once  or  twice  a  week.  For  this 
purpose,  one  and  a  half  drachms  of  Pulv.  Glycyrrhizae  Co.  or  two 
ounces  of  Mist.  Sennae  Co.  may  be  given. 

When  definite  symptoms  of  true  nephritis  are  present,  we 
cannot  hope  for  a  cure,  and  so  must  be  satisfied  either  to  ameliorate 
them,  if  we  can,  or  to  prevent  their  increasing  in  number  and 
severity.  The  quantity  of  urine  passed  daily  must  be  accurately 
measured  and  recorded,  as  an  important  index  of  the  progress  of 
the  case.  Milk  must  be  the  principal  diet.  Tarnier,  indeed, 
advises  that  it  should  be  the  sole  food  and  drink,  beginning  the 
treatment  by  gradually  diminishing  other  food  and  increasing  the 
quantity  of  milk,  till  as  much  milk  as  possible,  i.e.,  up  to  four 
quarts  daily,  is  taken,  and  no  other  food  or  drink.  Few  patients 
can  tolerate  this,  however,  and  it  is  more  usual  to  allow  milk 
puddings,  cornflour,  eggs,  vegetables,  and  fruit — but  little  or  no 
meat,  and  that  chiefly  chicken  and  fish.  Broths,  meat  extracts, 
and  alcohol  are  to  be  strictly  avoided.  The  more  severe  the 
case,  the  less  food,  other  than  milk,  is  allowed.  Any  con- 
tinuous diminution  in  the  amount  of  urine  calls  for  restriction 
of  diet,  and  cathartic  action  of  the  bowels  by  a  saline  draught 
such  as  one  or  two  ounces  of  Mist.  Sennae  Co.  Another  safe  and 
reliable  hydragogue  purgative  in  such  cases  is  one  drachm  of 
Pulv.  Jalapae  Co.  Diuretic  action  may  be  induced  by  five  to 
ten  minim  doses  of  the  tincture  of  digitalis  in  mixture,  or  by  the 
powdered  leaves  combined  with  mercury  and  squill  (gr.i.ss.  of 
each),  in  a  pill,  given  three  times  a  day.  If  there  is  no  improve- 
ment, the  patient  must  be  kept  in  bed  on  a  diet  of  milk 
alone,  and  be  freely  purged.  If  further  diuresis  is  required,  she 
should  be  placed  in  a  hot  pack  for  half  an  hour,  an  hour,  or  two 
hours,  according  as  it  is  seen  that  free  diaphoresis  is  induced,  and 
that  the  patient  appears  comfortable  and  quiet,  and  does  not 
show  signs  of  distress  or  weakness.  Other  means  of  inducing 
diaphoresis  are  drugs,  hot-vapour  baths,  and  hot-water  baths, 
but  they  do  not  appear  to  us  to  be  as  reliable  or  as  easily 
managed  as  is  the  hot  pack.  The  symptoms  which  point  to 
extreme  urgency  are  threatened  suppression  of  urine,  threatened 
cardiac  failure,  severe  dyspnoea,  constant  vomiting,  mental 
obscuration,  eye  symptoms  such  as  marked  amblyopia  or 
amaurosis,  marked  albuminuric  retinitis,  or  retinal  haemorrhages  ; 


586  THE  PATHOLOGY  OF  PREGNANCY 

and,  in  the  presence  of  these,  the  question  of  undertaking  the 
induction  of  labour  must  be  considered.  If  such  a  course  is  to 
be  adopted,  it  should  be  carried  out  with  the  least  possible  delay. 

The  chief  point,  so  far  as  the  obstetrical  treatment  of  the  case 
is  concerned,  is  the  question  of  the  induction  of  premature  labour, 
and  on  this  point  there  is  great  diversity  of  opinion.  Pregnancy 
has  a  distinctly  unfavourable  influence  upon  chronic  Bright's 
disease,  and,  for  this  reason,  some  writers  recommend  that  in 
a  well-marked  case  early  abortion  should  be  brought  about,  in 
order  to  save  the  mother  from  the  almost  certain  aggravation  of 
symptoms  and  the  possible  increase  in  the  disease.  Hoffmeier,* 
after  a  very  careful  consideration  of  all  the  bearings  of  such  cases, 
has  come  to  the  conclusion,  that,  in  chronic  nephritis,  pregnancy 
should  be  interrupted  artificially  in  the  interests  of  the  mother, 
when,  in  spite  of  suitable  treatment,  the  symptoms  of  the  disease 
become  worse,  or  even  when  they  do  not  improve.  This  view 
is  the  more  easily  accepted  when  we  remember  that  the  foetal 
mortality  amounts  to  50  or  60  per  cent. 

If  the  operation  is  to  be  successful  in  saving  the  life  of 
the  mother,  it  must  be  undertaken  before  her  condition  has 
reached  such  a  state  that  there  is  almost  complete  suppression 
of  urine,  and  threatened  uraemia.  It  is  necessary  to  carefully 
watch  the  case,  and  to  induce  labour  without  delay  if  it  is  seen 
that,  in  spite  of  treatment,  the  symptoms  are  tending  to  this 
termination. 

In  nephritis  due  to  pregnancy,  symptoms  arise  as  a  rule  in  the 
later  months,  and  the  induction  of  labour  is  seldom  required. 
Pajot  is  of  opinion  that  labour  should  never  be  induced  in  the 
kidney  of  pregnancy,  as  he  considers  the  operation  more  dangerous 
than  eclampsia  itself.  Hoffmeier,  however,  considers  that  in  view 
of  the  danger  of  eclampsia,  artificial  interruption  of  pregnancy  is 
indicated  if,  in  spite  of  suitable  dietetic  treatment,  the  symptoms 
steadily  become  more  serious.  With  this  view  we  agree,  as,  in 
such  cases,  if  pregnancy  does  not  come  to  an  end,  the  death  of 
the  patient  is  almost  certain. 

Prognosis. — Nephritis  is  one  of  the  most  common  causes  of 
recurring  death  of  the  foetus  in  utero,  and  is  also  most  dangerous 
to  the  life  of  the  mother.  Apart  from  the  consequences  of 
eclampsia,  sixty  per  cent,  of  children  are  lost  in  nephritis,  either 
by  death  in  utero  or  by  premature  delivery  before  viability.! 
Hoffmeier  places  the  maternal  mortality  of  nephritis  alone  at 
thirty-three  per  cent.  This,  he  admits,  is  probably  too  high, 
many  of  the  cases  being  severe  ones,  and  sent  to  the  public 
hospital  on  that  account.  Still,  the  mortality  is  very  high,  and 
the  earlier  the  symptoms  of  disturbed  compensation  the  higher  it 
becomes.  It  is  probable  that  it  is  higher  than  even  statistics 
show,  for  the  evil  effect  of  pregnancy  on  the  nephritis  does  not 
end  with  labour  ;  the  pregnancy  has  reacted  on  the  whole  renal 
*  Internat.  Cong.  Gynaecol. ,  1902.  f  Hoffmeier,  loc.  tit. 


CARDIAC  DISEASE  5S7 

and  vascular  system,  and  may  have  a  remote  and  fatal  effect  beyond 
the  period  which  would  be  included  in  obstetrical  statistics. 

It  is  difficult  to  say  what  is  the  mortality  resulting  from  the 
kidney  of  pregnancy,  as  statistics  usually  deal,  not  with  the  condi- 
tion itself,  but  with  the  associated  eclampsia.  The  occurrence  of 
eclampsia  is  relatively  frequent  in  this  form  of  nephritis,  and  in 
the  former  the  mortality  varies  from  twelve  to  thirty  per  cent. 


CARDIAC  DISEASE 

The  relation  of  cardiac  disease  to  pregnancy  is.  as  a  rule,  very 
inadequately  dealt  with  in  English  works  on  obstetrics.  Angus 
MacDonald's  monograph,  published  as  long  ago  as  1877  in  the 
Obstetrical  Journal,  is  still  perhaps  the  most  valuable  contribution 
on  the  subject,  and  he,  at  that  time,  complained  of  the  scant 
manner  in  which  cardiac  disease  was  dealt  with  by  writers  on 
obstetrical  subjects,  and  the  complaint  is  still  justified. 

Text-books  on  midwifery  nearly  all  mention  organic  disease  of 
the  heart  in  relation  to  pregnancy,  but  these  references  are  usually 
vague  and  general,  and,  as  a  rule,  no  attempt  is  made  to  differ- 
entiate between  the  different  forms  and  their  special  effects  on 
pregnancy  and  parturition.  It  is  only  by  such  considerations, 
however,  that  we  can  form  any  intelligent  estimate  of  the  addi- 
tional risks  that  pregnancy  and  parturition  impose,  and  of  the 
measures  we  must  adopt  so  as  to  avoid  or  diminish  such  risks. 

We  may  here  confine  ourselves  to  the  consideration  of  the 
effects  of  valvular  lesions  of  the  heart,  and  only  those  of  the  left 
side  need  be  dealt  with.  Further,  aortic  stenosis  by  itself  is  so 
rare,  that  it  may  be  ignored,  and  consequently  the  varieties  that 
must  be  considered  are  the  following  : — Aortic  regurgitation,  alone 
or  combined  with  stenosis  ;  mitral  regurgitation  ;  mitral  stenosis  ; 
mixed  aortic  and  mitral  lesions. 

We  propose  to  first  discuss  the  general  relations  of  cardiac 
disease  to  pregnancy  and  its  treatment,  and  then  to  discuss  the 
particular  consequences  and  treatment  of  the  different  forms  of 
valvular  disease. 

Larcher,  in  1825,  was  the  first  to  point  out  that  during  preg- 
nancy under  normal  conditions  the  heart  hypertrophies,  in  conse- 
quence of  the  increased  work  it  has  to  do,  and  the  larger  vascular 
area  it  supplies.  This  hypertrophy  is  for  the  most  part  confined 
to  the  left  ventricle,  as  although  the  needs  of  the  fcetus  throw 
increased  work  on  the  pulmonary  circulation  also,  the  latter  is 
not  so  greatly  increased  as  to  call  for  a  marked  hypertrophy  of 
the  right  ventricle.  It  has  been  suggested  that  the  involution  of 
the  heart  after  pregnancy  may  not  be  so  complete  that  it  returns 
to  its  original  condition,  and  that  thus,  repeated  pregnancies, 
especially  if  they  recur  rapidly,  may  induce  a  condition  of  per- 
sistent hypertrophy.     It  is  conceivable    that    this  may  in   some 


588  THE  PATHOLOGY  OF  PREGNANCY 

cases  occur,  and,  if  so,  it  is  possible  that  this  may  change  the 
diameter  of  the  mitral  or  of  the  aortic  orifice,  or  of  both,  and 
thus  lead  to  insufficiency,  without  any  other  morbid  condition. 
Such  an  occurrence  must,  however,  be  extremely  rare. 

It  is  easy  to  understand  how  the  occurrence  of  pregnancy 
causes  a  rapid  development  of  the  symptoms  of  a  hitherto  latent 
cardiac  lesion.  The  enormous  and  rapidly  increasing  area  of  the 
uterus  with  its  decidual  and  placental  vessels,  together  with  the 
increasing  quantity  of  blood,  give  the  heart  an  increased  and  in- 
creasing amount  of  work.  If,  before  pregnancy,  the  heart  had  a 
leaking  or  stenosed  valvular  opening,  it  hypertrophied  to  compen- 
sate for  this  ;  but  now  it  is  called  on  to  hypertrophy  still  more,  and 
militating  against  its  ability  to  do  so-i's  the  fact  that'  the  nutritive 
quality  of  the  blood  is  inferior  and  daily  becomes  more  so,  as  it 
carries  the  foetal  as  well  as  the  maternal  impurities.  In  addition 
to  this,  the  freedom  of  action  of  the  heart  is  becoming  impeded  by 
pressure  due  to  the  increasing  size  of  the  uterus,  so  that  the  ex- 
cursions of  the  diaphragm  are  less  free.  This  pressure  not  only 
displaces  the  heart  upwards,  but  limits  the  full  expansion  of  the 
lungs,  so  limiting  their  oxygenating  power  on  the  blood.  Hence 
it  is  that  the  compensating  power  of  the  heart  rapidly  fails,  when, 
to  a  valvular  lesion,  is  superadded  the  increased  strain  of  pregnancy. 
We  are  aware  that  Dohrn,  Kiichenmeister,  and  others  have 
maintained,  as  the  result  of  their  measurements  and  experiments, 
that  the  total  capacity  of  the  lungs  of  the  human  female  is  con- 
stant throughout  normal  pregnancy.  Still,  it  is  difficult  to  believe 
this,  as  the  increased  frequency  of  respiration,  its  shallowness, 
and  the  ease  with  which  dyspnoea  comes  on,  all  point  to  a  limita- 
tion of  the  capacity  and  the  expansion  of  the  lungs.  However, 
whatever  may  be  the  condition  in  health,  there  is  no  question 
that  the  upward  pressure  of  the  diaphragm  has  an  injurious  effect 
on  a  damaged  heart. 

The  time  at  which  the  symptoms  of  failing  compensation 
manifest  themselves,  and  the  rapidity  with  which  they  develop, 
depend  on  the  degree  of  the  valvular  lesion  and  the  previous 
condition  of  health  of  the  patient.  In  a  first  pregnancy,  these 
symptoms  may  not  at  any  time  become  urgent,  but  they  seldom 
fail  to  become  so  in  a  subsequent  pregnancy.  The  usual  period 
at  which  they  manifest  themselves  is  just  about  the  mid-term 
of  pregnancy,  that  is,  about  the  fifth  month.  As  the  case 
progresses,  the  woman  may  die  from  the  effects  of  the  cardiac 
lesion  during  pregnancy,  premature  expulsion  of  the  ovum  may 
occur,  or  pregnancy  may  continue.  If  she  reaches  full  term, 
labour  may  prove  fatal.  Even  after  labour  has  been  successfully 
accomplished,  it  is  not  uncommon  for  the  mother  to  die,  within  a 
few  days,  weeks,  or  even  months,  as  a  late  result  of  the  associa- 
tion of  pregnancy  and  heart  disease. 

Various  explanations  have  been  offered  of  the  relatively  fre- 
quent  premature  expulsion  of   the   ovum  in  cardiac  cases.     In 


CARDIAC  DISEASE  589 

some  cases,  it  appears  as  if  venous  congestion  leads  to  dilatation 
of  the  placental  vessels  with  rupture  and  separation  of  the 
placenta.  In  others,  the  onset  of  labour  appears  to  be  due  to 
cyanosis,  which  causes  the  stimulation  of  the  uterine  centres  by 
the  accumulation  of  C02  in  the  blood. 

General  Treatment  of  Cardiac  Lesions. — The  treatment  of  cardiac 
lesions  commences,  not  with  the  period  of  gestation,  but  on  the 
first  recognition  of  a  cardiac  lesion,  whenever  that  may  be.  A 
woman  known  to  have  cardiac  disease  should  be  carefully 
watched  for  the  slightest  indication  of  commencing  failure  of 
compensation,  if  there  is  any  likelihood  of  her  being  pregnant.  If 
symptoms  appear,  she  should  be  confined  to  bed,  and  digitalis  or 
strophanthus  administered  until  compensation  is  again  established. 
In  any  case,  even  though  no  cardiac  symptoms  are  present,  her 
general  health  should  be  diligently  watched,  the  bowels  kept  open, 
and  rest  enjoined.  If  she  becomes  pregnant,  these  precautions  are 
doubly  important.  Should  failure  of  compensation  occur  in  spite  of 
all  precautions,  and  the  symptoms  increase  in  gravity,  the  medical 
man  must  be  prepared  to  bring  the  pregnancy  to  an  end  at  any 
time  if  it  is  found  to  be  necessary  to  do  so.  The  question  of  the 
propriety  of  inducing  labour  in  cardiac  disease  is  a  difficult  one,  and 
is  still  unsettled.  Jardine  says  : — '  The  results  from  induction  are 
so  bad,  that  I  am  inclined  to  question  the  propriety  of  doing  the 
operation.  The  risk  is  exceedingly  great.  In  a  bad  case,  I  should 
advise  the  induction  of  abortion  before  the  fourth  month,  i.e., 
before  the  extra  strain  has  begun  to  tell  on  the  heart,  but  in  the 
later  months  I  should  be  very  loth  to  interfere.'  The  general 
teaching  of  text-books  also  is  against  inducing  labour,  our 
examination  of  isolated  and  collected  cases  tends  to  support 
this  teaching,  and  MacDonald  definitely  held  the  same  opinion. 
There  have  been,  however,  great  advances  since  MacDonald's 
time,  in  the  methods  of  inducing  labour  and  of  rapidly  empty- 
ing the  uterus,  and  in  the  future,  as  experience  is  gained,  these 
may  enable  us  to  take  a  less  pessimistic  view  of  a  treatment 
which  appears  in  some  cases  to  give  the  only  possible  hope  of 
relief. 

Our  own  views  on  the  treatment  of  cardiac  cases  may  be  briefly 
summed  up  as  follows.  If  the  symptoms  of  the  patient  are  slight, 
and  we  have  reason  to  believe  that  sufficient  compensation  will 
occur  to  carry  her  safely  through  pregnancy,  the  latter  should  be 
allowed  to  continue.  If  the  patient  is  seen  at  an  early  stage  of 
pregnancy,  while  the  heart  is  still  working  properly,  but  from 
her  history  we  have  reason  to  believe  that  its  ultimate  failure  is 
probable,  labour  should  be  induced  before  any  symptoms  of 
failing  compensation  appear.  If,  on  the  other  hand,  the  patient  is 
not  seen  until  marked  cardiac  symptoms  have  occurred,  attempts 
should  be  made  to  restore  compensation.  If  these  attempts  are 
successful,  labour  should  then  be  induced,  lest  a  recurrence  of 
the  symptoms  should   occur,  with  probably  fatal  consequences. 


59o 


THE  PATHOLOGY  OF  PREGNANCY 


Similarly,  if  our  efforts  at  restoring  compensation  fail,  the 
condition  of  the  patient  is  desperate,  and  the  induction  of  labour 
should  still  be  carried  out,  as  it  affords  a  small  hope,  whereas 
if  pregnancy  is  allowed  to  continue  there  is  none.  The  evil  results 
of  leaving  cardiac  cases  until  the  severity  of  the  symptoms  induce 
spontaneous  delivery  is  seen  in  the  fact  that  of  fourteen  cases 
recorded  by  MacDonald  and  Gardiner  in  which  premature 
delivery  came  on,  only  three  recovered,  and  these  were  cases  of 
aortic  disease. 

Whether  labour  is  induced  or  comes  on  at  full  term,  it  should 
be  terminated  as  rapidly  as  possible.  Digitalis  or  strophanthus 
and  stimulants  may  be  freely  given  ;  anaesthetics  are  well  borne, 
and  should  be  used ;  if  there  is  the  least  delay  in  progress,  the 
os  should  be  artificially  dilated  by  Bossi's  or  Frommer's  dilator, 
and  the  child  extracted  with  the  forceps.  In  the  third  stage  of 
labour,  the  loss  of  a  certain  amount  of  blood  is  advisable,  and, 
consequently,  active  measures  to  prevent  a  loss  need  not  be  at 
once  taken.  If  the  uterine  haemorrhage  is  scanty,  and  there  are 
signs  of  cardiac  engorgement,  a  vein  should  be  opened  in  the 
arm.  If  there  is  great  oedema  of  the  vulva,  the  labia  may  require 
to  be  freely  punctured  at  the  commencement  of  labour  with  strict 
antiseptic  precautions,  and  allowed  to  drain  into  sterile  dressings. 
Strychnine  (~  gr.),  with  digitalin  (T^  to  —  gr.),  given  hypoder- 
mically,  will  be  found  serviceable  in  combating  the  cardiac  weak- 
ness, and  in  aortic  cases  Nitrite  of  Amyl  may  prove  of  use  in 
lowering  the  blood-pressure  and  relieving  the  strain  on  the  heart. 

The  nursing  of  the  infant  should  be  prohibited  in  even  the 
mildest  cases.  The  call  it  makes  on  the  strength  and  nutri- 
tion of  the  patient  is  most  injurious  to  the  heart  in  its  endeavour 
to  recover  from  the  strain  of  pregnancy  and  parturition,  and  to 
regain  its  full  compensation. 

Prognosis. — The  following  table  shows  the  results  of  28  cases, 
which  MacDonald  has  met  with  himself  or  collected  from  various 
trustworthy  sources  : — 


Nature  of  Lesion. 

Number  of  Cases. 

Deaths. 

Percentage. 

Mitral  stenosis 
Mitral  regurgitation 
Aortic  regurgitation    . . 
'  Dilated  weak  heart  ' 
'  Plastic  endocarditis  ' 
Ulcerative  endocarditis 

Total 

12 

8 

5 

1 
1 
1 

9 
3 
2 

1 
1 
1 

75 

37'5 

40 
100 
100 
100 

28 

17 

607 

Thus,  in  twenty-eight  cases  there  were  seventeen  deaths,  or 
6o*7  per  cent.,  and  of  these  seventeen  fatal  cases,  ten  were 
primiparae.     '  This,'  as  MacDonald  says,  '  in  cases  presenting  no 


MITRAL  STENOSIS  591 

purely  obstetric  cause  likely  to  lead  to  increased  mortality,  leaves 
it  beyond  question  that  the  combination  (of  pregnancy  and  cardiac 
disease)  is  extremely  liable  to  prove  fatal.' 

Jardine*  has  given  carefully  detailed  notes  of  thirteen  cases  in 
his  own  practice,  and  from  these  and  others  which  he  has  observed 
he  draws  valuable  conclusions  as  to  management.  In  the  reported 
cases,  he  was  very  fortunate  in  losing  only  one  patient,  though 
several  patients  had  mitral  stenosis. 

The  most  serious  lesion  appears  to  be  mitral  stenosis  ;  after 
that  aortic  regurgitation  ;  and  then  mitral  regurgitation,  alone  or 
combined  with  stenosis  or  an  aortic  lesion. 

Finally,  the  question  must  be  answered,  Should  a  woman  with 
valvular  disease  marry  ?  The  answer  to  the  friends  or  relatives 
of  the  patient  must  be  '  No.'  Our  advice  will  probably  not  be 
taken,  but,  all  the  same,  it  should  be  given,  and  none  the  less 
definitely  on  that  account.  There  is  no  use  in  '  hedging '  by 
saying  that,  if  failure  of  compensation  has  ever  occurred,  or  if  the 
damage  to  the  valve  is  considerable,  or  if  some  particular  valve  is 
involved,  she  should  not  marry.  In  view  of  the  sequence  of  events 
which  we  know  to  be  usual  in  any  case  of  valvular  lesion,  and 
remembering  that  a  woman  has  duties  as  a  wife  and  as  a  mother 
which  require  her  health  and  strength  for  their  due  performance, 
there  should  be  no  hesitation  in  the  mind  of  the  physician  as  to 
what  answer  he  would  give  to  such  an  enquiry. 

It  is  astonishing  how  frequently  the  question  is  raised  in  text- 
books, and  how  evasively  it  is  answered.  That  '  the  perils  of 
marriage  should  be  clearly  stated  to  both  the  contracting  parties,' 
as  advised  by  a  very  recent  American  treatise  on  '  The  Heart,' 
is  not  the  way  out  of  the  difficulty.  The  physician  has  many 
puzzling  questions  to  answer,  but  this  is  not  one  of  them,  and,  as 
his  opinion  has  been  asked,  it  should  be  given  in  a  definite  and 
unequivocal  manner. 

Mitral  Stenosis. — As  is  well  known,  mitral  stenosis  is  more 
commonly  met  with  in  females  than  in  males,  though  the  reason 
is  not  obvious.  Its  onset  is  very  frequently  insidious,  no  history 
of  an  attack  of  rheumatism  being  forthcoming,  although  generally 
vague,  but  slight,  pains  have  been  noticed  in  the  joints.  The 
subjects  of  mitral  stenosis  are  usually  thin,  anaemic,  and  weakly, 
and  suffer  from  cold  extremities.  They  seem  to  have  less  blood 
than  normal — the  stream  passing  through  the  narrow  mitral 
opening  only  affording  a  small  volume  for  the  ventricle  to  send  on 
at  each  systole.  It  is  probably  for  this  reason  that  these  patients 
make  such  a  poor  fight  during  pregnancy. 

Urgent  symptoms  most  frequently  arise  in  the  second  stage  of 
labour,  and  call  for  prompt  measures.  These  symptoms  are 
irregularity  of  pulse,  cyanosis,  and  threatening  or  actual  syncope. 
It  is  the  '  bearing-down  '  of  this  stage  that  so  increases  the  danger. 
During  this  time  the  lungs  are  tensely  filled  with  air,  the  glottis 
*  Journal  of  Obstetrics,  1902. 


592  THE  PATHOLOGY  OF  PREGNANCY 

closed,  the  diaphragm  depressed,  and  the  whole  muscular  system, 
including  the  uterus,  in  a  state  of  strong  contraction.  In  con- 
sequence, the  blood  from  all  these  parts  is  driven  into  the 
veins,  and  thus  thrown  upon  the  already  overloaded,  overworked, 
and  exhausted  right  heart.  The  narrowed  mitral  opening  does 
not  allow  this  blood  to  be  freely  passed  on,  and  the  left  auricle 
and  the  right  heart  become  overdistended.  From  this  cause, 
paralysis  may  occur,  and  not,  as  Fritsch  has  explained,  from  a 
sudden  influx  of  blood  entering  tha  chambers  of  the  heart  when 
in  a  state  of  emptiness.  The  fall  in  blood-pressure  which  occurs, 
and  which  MacDonald  demonstrated  by  tracings,  is  thus  explained 
by  the  distended  left  auricle,  with  its  weakened  pulsations,  being 
unable  to  send  on  enough  blood  through  the  narrowed  mitral 
orifice  to  supply  the  left  ventricle.  Hence,  comes  the  irregular 
flickering  pulse  and  the  increasing  cyanosis  bringing  about  a 
gradual,  but  finally  profound,  narcosis,  which  will  end  in  death  if 
not  interrupted. 

Such  a  train  of  symptoms  appears  to  forbid  the  administration 
of  chloroform,  but  several  recorded  cases  go  far  to  prove  the 
contrary.  A  moderate  degree  of  chloroform  narcosis  lessens  or 
does  away  with  the  bearing-down  efforts,  which,  as  we  have  seen, 
have  such  an  evil  effect.  The  labour  may  then  be  ended  by  the 
application  of  the  forceps. 

On  the  completion  of  the  second  stage,  the  sudden  limitation  of 
the  vascular  area  by  the  cessation  of  the  placental  circulation  and 
the  contraction  of  the  uterus,  causes  an  increased  quantity  of 
blood  to  be  rapidly  thrown  on  the  right  side  of  the  heart,  and  this 
may  become  so  dangerously  embarrassed  in  its  already  weak  and 
distended  condition,  that  its  systole  may  fail  and  sudden  death 
occur.  Berry  Hart  has  published  such  a  case.  Death  occurred 
suddenly  after  delivery,  and  post-mortem  examination  showed  the 
right  side  of  the  heart  to  be  enormously  distended  and  full  of 
blood.  This  suggests  a  line  of  practice  which  is  advocated 
by  Hart,  and  warmly  supported  by  Jardine  in  the  paper  to 
which  we  have  already  referred — viz.,  that  at  the  time  of  labour 
rather  free  haemorrhage  from  the  uterus  should  be  encouraged,  so 
as  to  ease  the  heart,  and  prevent  engorgement.  If  the  uterine 
haemorrhage  is  not  sufficient  for  this  purpose  and  cardiac  em- 
barrassment begins  to  appear,  venesection  at  the  arm  should  be 
undertaken  without  delay.  Acting  on  these  lines,  Jardine  has 
had  remarkable  success.  Of  his  thirteen  reported  cases,  three 
were  mitral  stenosis,  and  three  combined  mitral  stenosis  and 
regurgitation.  All  six  made  an  excellent  recovery,  though  some 
of  them  were  very  serious,  and  required  artificial  aid  in  delivery  or 
the  induction  of  labour. 

When  labour  is  over,  a  hypodermic  injection  of  morphia  is  of 
material  aid  to  the  patient.  Morphia  acts  as  a  stimulant  to  the 
heart,  it  quiets  down  the  whole  system,  and  it  gives  the  patient 
a  much-needed  rest,  after  the  exhaustion  and  anxiety  of  labour. 


MITRAL  REGURGITATION  593 

The  administration  of   digitalis  and    strychnine  is   also  usually 
essential  in  the  after-treatment  of  the  case. 

Aortic  Regurgitation.  —  Aortic  regurgitation  is,  for  several 
reasons,  much  more  common  in  men  than  in  women,  and  though 
met  with  at  all  ages,  it  is  usually  found  in  the  latter  half  of  life, 
since  its  chief  cause  is  degenerative  change  in  the  aorta  or  its 
valves.  It  is  therefore  a  comparatively  rare  complication  of 
pregnancy. 

The  danger  arising  from  this  condition  is  most  marked  from 
the  mid-term  of  pregnancy  till  the  completion  of  the  second  stage 
of  labour.  The  increase  in  the  blood  quantity  and  blood-pressure 
during  pregnancy  tends  to  increase  the  regurgitation,  and  so  to 
disturb  the  compensation  of  the  left  ventricle  even  if  this  had  pre- 
viously become  adjusted.  Additional  cardiac  hypertrophy  is  greatly 
interfered  with  by  the  condition  of  the  blood,  and  by  interference 
with  the  action  of  the  heart  owing  to  increasing  abdominal  pressure 
on  the  diaphragm.  As  a  rule,  dyspnoea,  restlessness,  want  of 
sleep,  and  oedema  soon  manifest  themselves,  and  premature  labour 
results.  Whether  the  last  occurs,  or  whether  the  case  goes  to  full 
term,  it  is  hardly  necessary  to  point  out  that  the  greatly  increased 
strain  of  '  bearing  down  '  may  be  the  '  last  straw '  to  the  over- 
taxed ventricle — a  condition  of  asystole  is  very  prone  to  occur,  and 
cause  the  sudden  death  of  the  patient. 

The  second  stage,  therefore,  is  again  the  chief  period  of 
anxiety.  Bearing-down  efforts,  associated  with  a  great  increase 
in  the  blood  pressure,  bring  about  greater  regurgitation  into  the 
ventricle,  and  call  for  increased  lifting  power  on  the  part  of  the 
ventricle,  and  these  throw  such  an  enormous  strain  upon  the 
latter  that  it  becomes  unable  to  empty  itself.  Hence  it  is  that 
syncope  is  of  frequent  occurrence,  may  repeatedly  recur,  and  may 
prove  fatal,  and  hence,  also,  we  can  explain  the  beneficial  effects 
of  delivery  and  the  return  to  a  normal  blood-pressure. 

Of  the  different  forms  of  cardiac  lesion,  aortic  regurgitation  is 
the  one  in  which  the  greatest  benefit  might  be  expected  from  the 
induction  of  premature  labour.  To  be  of  benefit,  however,  it 
must  be  undertaken  as  soon  as  any  symptoms  of  distress  appear, 
otherwise  the  symptoms  will  progress  in  urgency  and  usually 
bring  on  labour,  which  then,  however,  gives  little  relief.  Even  if 
symptoms  are  absent  throughout  the  pregnancy,  they  almost 
certainly  appear  when  labour  sets  in.  Delivery  should  therefore 
be  accomplished  as  rapidly  as  possible,  the  os  being  dilated 
artificially,  and  bearing-down  efforts  being  lessened  as  much  as 
possible. 

Mitral  Regurgitation.  —  Mitral  regurgitation  is  the  most 
common  cardiac  affection,  and  perhaps  presents  the  greatest 
differences  in  degree.  The  fact  that  the  lesser  degrees  of  regur- 
gitation and  the  well-compensated  cases  preponderate,  gives  to 
this  condition  its  less  serious  position  relative  to  the  other 
cardiac  lesions.    On  the  other  hand,  when  regurgitation  is  extreme 

38 


594  THE  PATHOLOGY  OF  PREGNANCY 

and  when  tricuspid  regurgitation  is  added,  the  case  is  well-nigh 
hopeless.  This  is  the  condition  which  almost  inevitably  super- 
venes when  successive  pregnancies  occur  in  a  woman  with  an 
already  damaged  mitral  valve,  and  which  makes  the  prognosis 
in  all  cases  so  grave  for  the  married  woman  who  suffers  from 
mitral  regurgitation. 

Mitral  regurgitation  appears  to  be  a  less  grave  complication 
of  pregnancy  than  is  stenosis,  partly  because  as  a  rule  these 
patients  are  more  robust  than  are  those  with  stenosis,  and  so 
make  a  better  fight.  Premature  labour  also  is  not  so  liable  to 
occur  in  mitral  regurgitation,  and  a  much  larger  proportion  of 
cases  go  through  two  or  more  pregnancies.  Here-in,  however, 
lies  one  great  danger.  With  a  damaged  mitral  valve,  it  is  quite 
difficult  enough  for  the  heart  under  ordinary  circumstances  to 
keep  up  sufficient  compensation.  The  disturbances  of  pregnancy 
disorganise  that  compensation,  and  each  succeeding  pregnancy 
makes  matters  worse.  Each  pregnancy,  therefore,  is  attended 
with  more  marked  cardiac  symptoms  and  with  greater  danger 
than  was  the  previous  one,  until  eventually  the  limit  of  the  power 
of  compensation  of  the  heart  is  passed. 

In  this  condition,  the  hypertrophy  of  the  left  ventricle,  which 
occurs  with  pregnancy,  acts  disadvantageously  in  the  case  of  a 
leaking  valve,  as  the  hypertrophied  ventricle  throws  the  blood 
with  greater  force  back  on  the  already  dilated  auricle,  and  so 
increases  the  engorgement  of  the  lungs.  Hence,  oedema  and 
pulmonary  symptoms  with  haemoptysis  are  common.  This 
hypertrophied  condition  of  the  left  ventricle  affords  an  explanation 
why  there  is  not  a  greater  relief  of  symptoms  after  delivery. 
The  termination  of  pregnancy  has  no  immediate  effect  on  the  size 
and  strength  of  the  ventricle,  which  goes  on  pumping  back  its 
blood  through  the  leaking  valve  and  keeping  up  the  distension 
of  the  auricle  and  the  engorgement  of  the  lungs  and  right  heart. 
Thus  it  is  that,  though  labour  has  been  safely  and  perhaps  easily 
accomplished,  the  cardiac  symptoms  continue  and  delay  con- 
valescence, or,  it  may  be,  the  symptoms  increase  in  severity,  and 
after  weeks  or  even  months  cause  a  fatal  termination. 

During  labour,  the  serious  nature  of  the  case  is  shown  by 
irregularity  and  failing  power  of  pulse,  restless  dyspnoea,  and 
cyanosis.  When  any  of  these  appear,  the  second  stage  must  be 
carried  through  quickly,  and  with  little  strain  to  the  patient. 
Ether  should  be  used  for  producing  anaesthesia.  Under  the 
anaesthetic  bearing-down  efforts  are  stopped,  and,  the  muscles 
being  relaxed,  the  vessels  dilate,  circulation  goes  on  more  freely, 
and  the  blood-pressure  falls,  thus  relieving  the  heart.  If  necessary, 
the  os  should  be  dilated  artificially,  and  the  stage  completed  as 
rapidly  as  possible  by  the  forceps.  Free  haemorrhage  during  the 
third  stage  appears  to  be  of  real  benefit,  by  relieving  congestion 
and  preventing  engorgement  of  the  already  overloaded  right  side 
of  the  heart. 


HYPEREMESIS  GRAVIDARUM  595 

The  after-treatment  of  the  case  should  be  similar  to  that  which 
has  been  suggested  in  cases  of  mitral  stenosis. 

Combined  Aortic  and  Mitral  Lesions.  —  No  attempt  will  be 
made  to  discuss  mixed  cases  of  aortic  and  mitral  lesions.  It 
may,  however,  be  said  that  it  is  peculiar  how  often  the  rare 
condition  of  aortic  regurgitation  is  associated  with  mitral 
narrowing.  The  combination  is  a  serious  one,  as  the  addition  of 
mitral  narrowing  makes  the  consequences  of  the  aortic  regurgita- 
tion more  serious. 

In  mitral  narrowing  and  regurgitation,  the  symptoms  of 
stenosis  generally  predominate.  The  prognosis  is  naturally  more 
serious  than  when  either  condition  exists  alone. 


HYPEREMESIS  GRAVIDARUM 

Hyperemesis  gravidarum  is  the  term  applied  to  the  uncon- 
trollable vomiting  which  occasionally  attacks  pregnant  women. 
As  will  be  seen  when  its  aetiology  is  discussed,  it  is  perhaps 
more  correctly  regarded  as  a  symptom  of  various  pathological 
conditions  than  as  a  pathological  entity. 

Frequency. — Hyperemesis  is  fortunately  a  condition  which  is 
but  seldom  met  with.  According  to  Pick,  its  frequency  is  about 
one  in  a  thousand.  At  the  Rotunda  Hospital,  it  occurred 
15  times  amongst  20,000  labours. 

Aetiology. — Hyperemesis  occurs  in  conjunction  with  a  number 
of  very  different  pathological  conditions.  It  is  found  as  the  result 
of  different  gastric  and  intestinal  diseases,  in  association  with 
lesions  of  the  generative  tract,  as  apparently  a  pure  neurosis, 
and  in  conjunction  with  other  symptoms  which  all  point  to  the 
presence  of  a  profound  auto-intoxication.  The  principal  gastric 
and  intestinal  disturbances  which  may  give  rise  to  uncontrollable 
vomiting  are  gastric  ulcer,  inflammatory  conditions  of  the  stomach 
or  intestinal  wall,  and  more  rarely  partial  or  complete  obstruction 
either  occurring  in  consequence  of  the  uterine  enlargement  or  as  an 
accidental  concomitant  of  pregnancy.  Lesions  of  the  generative 
tract  have,  in  the  past,  been  frequently  put  down  as  the  cause  of 
hyperemesis,  particularly  uterine  displacements,  cervical  lacera- 
tions and  erosions,  and  endometritis,  and  such  conditions  may  be 
a  cause  of  reflex  irritation  sufficient  to  produce  gastric  disturb- 
ances. We  doubt,  however,  that  they  ever  cause  vomiting  so 
severe  as  to  be  properly  called  hyperemesis.  A  pure  neurosis, 
in  the  form  of  hysteria,  may  sometimes  be  sufficient  to  cause 
vomiting,  even  to  such  an  extent  that  the  condition  of  the  patient 
becomes  critical.  Williams  relates  a  case  in  which  the  patient, 
who  had  vomited  incessantly  for  several  weeks,  was  immediately 
cured  when  he  drew  a  vivid  picture  of  the  dangers  of  inducing 
abortion,  and  informed  her  that  such  a  course  would  be  necessary. 
The  most  important  cause  of  uncontrollable  vomiting  is,  perhaps, 

38-2 


596  THE  PATHOLOGY  OF  PREGNANCY 

however,  the  auto-intoxication  which  sometimes  occurs  during 
pregnancy  in  the  case  of  patients  who  neglect  the  ordinary 
hygienic  precautions  of  pregnancy,  and  in  whom  there  is  a 
failure  of  the  eliminatory  functions  of  the  body.  Such  cases 
commence  with  morning  sickness  and  constipation,  and  are 
usually  associated  with  renal  disease  and  partial  suppression  of 
urine.  The  aetiology  of  hyperemesis  is  closely  allied  with  that 
of  eclampsia.  Both  conditions  are  found  as  the  result  of  reflex 
irritation  of  the  higher  centres,  and  of  auto-intoxication,  and 
both  conditions  are  most  frequently  found  in  association  with 
renal  disease.  The  resemblance  has  been  still  more  emphasised 
by  the  fact  that  several  observers*  have  reported  cases  of 
hyperemesis  in  which  the  post-mortem  examination  showed  the 
presence  of  lesions  of  the  kidney,  liver,  and  other  organs  identical 
with  those  observed  in  eclampsia. 

Symptoms. — The  essential  symptom  is  the  occurrence  of  severe 
vomiting  occurring  at  all  hours  of  the  day,  and  brought  on  by 
any  slight  stimulus — such  as  a  sudden  movement,  a  loud  noise, 
a  bright  light,  or  by  the  taking  of  food.  The  vomited  matter 
consists  of  the  ordinary  contents  of  the  stomach,  with  the 
addition  of  acid  mucus,  and  of  slight  traces  of  blood,  the  result 
of  straining.  In  serious  cases,  the  patient  is  usually  completely 
constipated,  and  the  amount  of  urine  passed  is  very  small.  The 
breath  is  most  offensive.  The  skin  is  dry,  and  perhaps  slightly 
jaundiced.  The  lips  and  mouth  are  also  dry,  and  sordes  accumu- 
late about  the  teeth.  The  patient  becomes  more  and  more 
debilitated  and  emaciated.  Her  pulse  is  small,  frequent,  and 
finally  irregular,  and  her  temperature,  which  in  the  early  stages 
of  the  condition  may  be  subnormal,  rises  as  the  condition  becomes 
worse  to  io3°-io4°  F. 

Treatment. — The  prophylactic  treatment  of  hyperemesis  is  of 
considerable  importance,  especially  in  cases  in  which  the  ordinary 
morning  sickness  of  pregnancy  shows  any  sign  of  being  unduly 
violent  or  prolonged.  It  consists  in  the  adoption  of  the  usual 
measures  for  allaying  morning  sickness,  in  the  regulation  of  the 
bowels,  and  in  the  removal  of  any  source  of  reflex  irritation  from 
the  genital  tract.  In  addition,  the  urine  should  be  examined  with 
a  view  to  the  early  detection  of  any  form  of  renal  disease. 

The  curative  treatment  of  hyperemesis  consists  first  of  all  in 
efforts  to  ascertain  the  exact  cause  of  the  sickness.  Clinically, 
two  classes  of  case  are  met  with  : — first,  cases  of  a  comparatively 
mild  type,  which  get  well  when  their  cause  is  removed ;  and, 
secondly,  cases  of  a  more  severe  type,  dependent  on  functional  or 
organic  disease.  The  treatment  of  the  former  class  is  directed  to 
the  removal  or  cure  of  any  sources  of  reflex  irritation,  such  as 

*  Bouffe  de  Saint-Blaise,  '  Les  Auto-intoxications  gravidiques,'  Annates  de 
Gyn.  et  d'Obstet.,  1898,  vol.  i.,  pp.  342-374,  and  432-455;  and  Dirmoser, 
'  Der  vomitus  gravidarum  perniciosus,'  Wien,  1901  ;  Pick.  '  Ueber  Hyper- 
emesis grav.,'  Volkmann's  Sammlung  Klin.  Vortrdge,  N.F.,  1902,  Nos.  325,  326. 


HYPEREMESIS  GRAVIDARUM  597 

uterine  displacements,  cervical  inflammations,  etc.,  the  regulation 
of  the  bowels,  and  the  administration  of  any  of  the  usual  anti- 
emetic drugs.  In  cases  due  to  hysteria  or  other  neurotic  con- 
dition, suggestion  is  sometimes  of  use,  as  in  the  case  recorded  by 
Williams.  If  it  fails,  the  administration  of  sedatives  in  fairly 
large  doses,  such  as  chloral  hydrate  or  bromide  of  potassium  will 
often  bring  about  the  necessary  depressant  effect  on  the  nervous 
system  and  will  check  the  vomiting.  They  will  in  most  cases  have 
to  be  given  by  the  rectum,  as  if  given  by  the  mouth  they  will  be 
immediately  rejected.  The  treatment  of  the  more  severe  cases 
due  to  profound  auto-intoxication  is  a  far  more  difficult  matter. 
The  general  lines  of  treatment  are  practically  identical  with  those 
recommended  for  a  similar  condition  occurring  in  connection  with 
eclampsia.  The  bowels  must  be  evacuated  by  purgatives  and 
injections.  The  action  of  the  kidneys,  if  deficient,  must  be 
stimulated,  and  also  the  action  of  the  skin.  Hot  baths,  if  the 
patient's  condition  permits  them,  wet  packs,  and  vapour  baths 
are  indicated.  If  possible,  the  patient  must  be  got  to  retain 
fluids  given  by  the  mouth,  and  saline  infusions  into  a  vein  or  into 
the  cellular  tissue  may  prove  of  use.  All  sources  of  reflex  irritation 
must  be  removed,  and  with  this  object  the  patient  must  be  kept 
in  a  quiet  and  darkened  room.  If,  as  is  usually  the  case,  nourish- 
ment cannot  be  given  by  the  mouth,  rectal  feeding  must  be  resorted 
to.  If  these  measures  fail,  as  a  last  resource,  abortion  or  premature 
labour  as  the  case  may  be,  must  be  induced,  and,  if  benefit  is 
to  be  obtained,  the  procedure  must  not  be  postponed  too  long. 
There  is  a  natural  tendency  to  avoid  such  extreme  measures  as 
long  as  possible,  and  the  most  difficult  point  in  the  management 
of  the  case  is  the  recognition  of  the  moment  at  which  they  can 
no  longer  be  postponed.  It  is  impossible  to  lay  down  a  rule  to 
govern  the  time  at  which  their  adoption  is  necessary,  but,  speak- 
ing generally,  as  soon  as  the  patient's  condition  is  such  as  to  give 
rise  to  anxiety,  and  is  becoming  daily  worse,  in  spite  of  the 
adoption  of  the  treatment  which  we  have  outlined,  labour  should 
be  induced.  If  it  is  to  be  induced  at  all,  it  must  be  before  her 
condition  becomes  so  critical  that  there  is  little  or  no  hope  of 
benefit  resulting. 

Prognosis. — Mild  cases  of  hyperemesis  due  to  a  removable  reflex 
cause  are,  as  we  have  said,  usually  cured  by  the  removal  of  the 
cause,  and  consequently  the  prognosis  is  distinctly  good.  The 
prognosis  of  the  other  class  of  cases  is  however,  extremely  bad, 
inasmuch  as,  as  a  rule,  the  patients  are  rarely  seen  in  time  to 
restore  the  action  of  the  eliminatory  organs.  In  hospital  practice, 
especially,  patients  suffering  from  hyperemesis  rarely  come  under 
treatment  until  they  are  so  far  gone  that  they  are  unable  to  stand 
even  the  manipulations  necessary  for  the  induction  of  labour. 


598  THE  PATHOLOGY  OF  PREGNANCY 


J  ECLAMPSIA 

Eclampsia  is  the  term  applied  to  epileptiform  attacks  occurring 
in  pregnant  or  puerperal  women,  which  are  the  manifestations  of 
a  cerebral  intoxication  or  over-activity  arising  as  an  indirect 
result  of  the  pregnancy.  By  thus  defining  eclampsia,  we  wish  to 
make  it  clear  that  it  is  not  a  term  to  be  applied  to  one  particular 
form  of  convulsive  attack  which  occurs  during  pregnancy,  but  is 
rather  to  be  applied  to  any  form  of  convulsive  attack  which  may 
occur  from  any  cause,  provided  that  cause  is  primarily  due  to  the 
effects  of  pregnancy  on  the  organism  of  the  patient. 

Frequency. — The  frequency  of  eclampsia  is  a  rather  difficult 
matter  to  ascertain.  If  the  statistics  of  lying-in  hospitals  are 
followed,  the  percentage  which  is  thus  obtained  will  be  too  high, 
as  there  will  always  be  found  in  hospitals  a  relatively  greater 
number  of  primiparae  than  of  multiparas,  and  also  as  a  patient  is 
more  likely  to  seek  the  aid  of  a  hospital  if  she  feels  herself 
seriously  ill,  than  if  she  is  expecting  her  confinement  in  her 
ordinary  health.  The  statistics  of  various  British  and  Continental 
hospitals  and  clinics  give  the  following  figures  : — Amongst  227,000 
patients  there  were  635  cases  of  convulsions  — i.e.,  a  proportion  of 
1  case  in  357*48.  All  these  cases  may  not  have  been  eclampsia, 
but  the  proportion  almost  exactly  corresponds  to  that  at  the 
Rotunda  Hospital,  where  amongst  20,000  patients  there  were 
56  cases  of  eclampsia,  a  proportion  of  1  in  357-14. 

Pathological  Anatomy. — At  the  autopsies  of  patients  who  have 
died  of  eclampsia,  a  tolerably  uniform  series  of  pathological  con- 
ditions are  met  with  in  the  various  organs.  The  organ  most 
constantly  affected,  and  the  one  whose  condition  is  most  closely 
connected  clinically  with  the  symptoms  of  the  case,  is  the  kidney. 
The  next  most  constantly  affected  organ  is  the  liver,  and  after  it 
the  brain.  There  is,  however,  no  one  lesion  which  has  come  to 
be  definitely  regarded  in  the  light  of  a  primary  lesion.  If  the 
various  organs  are  examined  one  by  one,  the  following  changes 
are  found : — 

The  Kidneys. — In  from  90  to  95  per  cent,  of  cases  the  kidneys 
are  affected,  most  commonly  by  the  condition  known  as  preg- 
nancy kidney.  According  to  Leyden,*  this  is  not  a  true  nephritis, 
but  rather  the  result  of  simple  anaemia,  and  is  characterised  by  a 
fatty  infiltration  of  the  renal  epithelium,  especially  of  the  con- 
voluted tubes.  The  cause  of  this  anaemia  is  attributed  by 
Diihrssen,  Spiegelberg,  and  others,  to  spasm  of  the  renal  arteries, 
due  to  their  reflex  irritation  by  stimuli  from  the  genital  tract. 
Such  stimuli  are  furnished  by  the  contractions  or  great  distension 
of  the  pregnant  uterus,  by  the  entrance  of  the  head  into  the 
pelvis,    and  by  the  onset  of  labour.      Volhard   attributes  renal 

*  '  Einige  Beobacktungen  iiber  Nierenaffectionen,'  etc.,  Zeits.  f.  Klin. 
Med.,  1881,  ii.  171-191. 


THE  PATHOLOGICAL  ANATOMY  OF  ECLAMPSIA  599 

anaemia  to  the  blocking  of  the  nutrient  vessels  by  emboli  caused 
by  the  action  of  some  coagulation-producing  ferment  upon  the 
blood.  Much  more  rarely  the  lesions  of  true  chronic  nephritis 
are  found  associated  with  eclampsia,  and  in  a  very  small  pro- 
portion of  cases  the  renal  changes  can  be  attributed  to  the  effects 


^ 

% 


Fig.  285. — Area  of  Necrosis  in  Eclamptic  Liver,      x  90.     (Williams.) 

of  obstructive  suppression  of  the  urine,  due  to  pressure  on  the 
ureters  (Halbertsma*). 

The  same  areas  of  necrosis  as  are  found  in  the  liver  are  also  to 
be  sometimes  found  in  the  kidneys,  and  can  be  attributed  to  like 
causes. 

*  '  Ueber  die  yEtiologie  der  eklampsia  puerperalis,'  Volkmann's  Saminlung 
Klinische  Vortrage,  1884,  No.  212. 


600  THE  PATHOLOGY  OF  PREGNANCY 

The  Liver.  —  Ecchymoses  are  frequently  scattered  over  the 
surface  of  the  liver.  Some  of  these  are  the  size  of  a  pin's 
head,  while  others  may^be  half  the  size  of  the  palm  of  the 
hand.  On  section,  the  colour  of  the  liver  substance  is  more 
yellow  than  usual,  owing  to  varying  lesions  of  the  epithelium 
(Pilliet*).  Haemorrhages,  resembling  the  sub-capsular  haemor- 
rhages, are  found  scattered  round  the  portal  interspaces,  and 
under  the  microscope  are  seen  in  three  different  stages.  In 
the  first  stage,  they  consist  of  a  circular  area  of  dilated  intra- 
lobular capillaries,  situated  close  to  a  portal  space,  and  about 
the  size  of  a  grape-stone.  In  the  second  stage,  these  areas  of 
engorgement  have  increased  in  size.  Round  their  periphery 
there  is  a  ring  of  dilated  capillaries,  while  the  centre  has  become 
necrotic,  and  consists  of  a  mass  of  dead  liver  cells,  blood 
corpuscles,  vessels,  and  fibrin.  In  the  third  stage,  the  areas  have 
still  further  increased,  and  in  places  where  they  were  near  one 
another  have  coalesced.  In  this  way,  islands  of  necrosis  are 
formed  surrounded  by  a  small-celled  exudation,  and  from  them 
emboli  of  liver  cells  (Jurgensf)  or  of  fat  (Virchow)  may  be  carried 
to  other  organs. 

There  is  a  wide  difference  of  opinion  with  regard  to  the  origin 
of  the  haemorrhages  which  produce  these  necrotic  areas,  as  we 
shall  see  in  discussing  the  various  theories  of  eclampsia.  Here,  it 
is  sufficient  to  say  that  they  may  occur  in  one  of  several  ways : — 
First,  as  the  result  of  the  bringing  to  the  liver,  in  the  blood,  of 
some  toxic  substance — chemical  or  bacterial  in  origin — which 
destroys  the  liver  cells  ;  secondly,  as  the  result  of  embolic  in- 
farction of  the  liver,  the  emboli  coming  from  the  placenta,  and 
being  formed  of  foetal  ectoblast  —  i.e.,  of  the  syncytium  and 
Langhans'  layer — or  being  formed  by  the  action  of  some  coagu- 
lation-producing ferment  on  the  blood;  and,  thirdly,  as  the  result 
of  the  rupture  of  small  bloodvessels  during  an  eclamptic  fit. 
Similar  areas  are  found  in  the  spleen,  kidney,  pancreas,  brain, 
and  lungs. 

The  Brain. — The  brain  is  sometimes  hyperaemic,  sometimes 
anaemic.  There  is  often  marked  oedema,  leading  to  consequent 
flattening  of  the  convolutions,  and  minute  haemorrhages  may 
occur  in  various  parts.  These  changes  are  in  all  probability  the 
result  of  increased  blood-pressure  during  a  convulsion. 

The  Spleen. — The  spleen  is  enlarged,  congested,  and  diffluent. 
Sub-capsular  haemorrhages  and  similar  areas  of  necrosis  as  are 
found  in  the  liver  are  sometimes  present. 

The  Pancreas. — The  pancreas  also  presents  areas  of  necrosis, 
and  may  be  markedly  anaemic. 

The  Lungs. — The  lungs  are  congested,  especially  at  their  bases. 

*  '  Lesions  du  foie  dans  l'eclampsie  avec  ictere,'  Nouv.  Arch.  d'Obstet.  et  de 
Gyn.,  1889,  iv.  312-367. 

•j-  '  Fettemboli  und  Metastase  von  Leberzellen  bei  Eklampsie, '  etc.,  Berliner 
Klin.  Wochenschr.,  1886,  519. 


THE  CAUSATION  OF  ECLAMPSIA  601 

There  are  also  sub-pleural  ecchymoses,  and  emboli  with  necrotic 
areas  are  found,  as  in  other  organs. 

The  Foetus  and  Placenta. — Somewhat  similar  conditions  have 
been  found  in  the  liver  and  kidneys  of  the  foetus,  as  are  described 
as  occurring  in  the  mother.  The  placenta  is  frequently  the 
subject  of  white  infarction,  a  condition  probably  due  to  the 
accompanying  renal  disease.  It  has  been  suggested  that  from 
these  areas  particles  formed  of  detached  portions  of  syncytium 
and  Langhans'  layer  may  pass  into  the  maternal  blood  and 
cause  coagulation,  as  well  as  acting  as  emboli. 

JEtiology. — Before  referring  to  the  numerous  theories  which 
have  been  brought  forward — for  the  most  part  in  a  vain  effort  to 
establish  eclampsia  as  a  specific  disease,  it  is  well  to  enumerate 
the  facts  that  are  known  regarding  its  occurrence.  We  know 
that  there  are  certain  conditions  which  predispose  to  the  occur- 
rence of  eclampsia.     These  are  as  follows  : — 

(i)  Acute  and  Chronic  Diseases  of  the  Kidney. — The  association 
of  albuminuria  with  eclampsia  is  perhaps  the  oldest  fact  known 
regarding  the  pathology  of  this  condition.  Until  comparatively 
recently,  it  was  believed  that  eclampsia  could  not  occur  apart  from 
albuminuria,  and  although  this  assumption  has  been  disproved, 
the  association  of  the  two  is  very  constant.  Out  of  195  cases  of 
eclampsia  recorded  by  Diihrssen  in  which  the  urine  was  examined, 
albumen  was  present  in  189  cases,  or  96  per  cent.  ;  considerable 
quantities  of  albumen  in  174  cases,  or  92  per  cent. ;  casts,  epi- 
thelium, etc.,  in  121  cases,  or  65  per  cent. ;  haemoglobinuria  in  4 
cases,  or  2  per  cent.  ;  and  urobilin  in  one  case.  Further,  there 
was  oedema  of  the  tissues  in  113  cases,  and  'other  evidence  of 
kidney  disturbance  '  in  25  cases.  The  nature  of  the  alterations  in 
the  kidney  substance  have  been  already  referred  to.  They  are  so 
very  various  that  it  is  probably  correct  to  assume  that  any  form 
of  renal  disease  may  be  found  in  association  with  eclampsia. 

(2)  Long  Retention  of  the  Excretions. — -Prolonged  constipa- 
tion and  failure  in  the  action  of  the  skin  and  kidneys  are,  as  a 
rule,  associated  with  eclampsia,  as  are  any  other  factors  that  tend 
to  cause  the  excessive  formation  of  toxins  in,  or  the  non-excretion 
of  toxins  from,  the  body.  In  this  category  may  be  included 
failure  in  the  hepatic  function,  and  possible  diminution  in  the 
secretion  of  the  thyroid  gland. 

(3)  Primiparity,  especially  in  Unduly  Young  or  Unduly  Old 
Women. — According  to  the  aggregated  statistics  of  a  number  of 
well-known  obstetricians,  eighty  per  cent,  of  patients  suffering 
from  eclampsia  are  primiparae.  In  the  195  cases  recorded  by 
Diihrssen,  40*5  per  cent,  were  either  below  twenty  or  over  thirty. 

(4)  A  neurotic  temperament,  especially  if  hereditary. 

(5)  Excessive  size  of  the  uterus,  as  in  hydramnios  and  multiple 
pregnancy. 

(6)  Obstructed  delivery. 

The  number  of  theories  which  have  been  advanced  to  account 


602  THE  PATHOLOGY  OF  PREGNANCY 

for  the  occurrence  of  eclampsia  is  sufficient  evidence  of  the  un- 
certainty with  which  the  pathology  of  the  disease  is  surrounded. 
The  most  important  of  these  theories  are  the  following  : — 

Frerichs'  Theory. — Frerichs'  theory,  that  eclampsia  is  due  to  the 
presence  in  the  blood  of  urea,  or  of  carbonate  of  ammonium 
formed  from  urea  under  the  influence  of  some  fermentative 
process,  is  untenable  for  several  reasons..  There  has  not  been 
found  any  storage  of  urea  in  the  liver  or  muscles  in  the  case  of 
patients  who  have  died  of  eclampsia ;  nor,  in  the  case  of  those 
who  recover,  is  there  any  increased  quantity  excreted.  Further- 
more, urea  has  been  injected  into  the  blood  without  causing 
convulsions.  Bouchard  even  attributes  a  diuretic  effect  to  it, 
and  under  his  advice  Pinard  employed  it,  as  a  hypodermic  injec- 
tion, in  1887,  in  the  case  of  anuric  eclamptics.  The  carbonate 
of  ammonium  theory  has  been  overthrown  by  Bernard,  who 
demonstrated  the  fact  that  it  was  present  in  the  same  proportion 
in  the  blood  of  a  healthy  man  as  in  that  of  an  eclamptic. 

The  Bacterial  Theory.— The  bacterial  theory  of  eclampsia  has 
never  made  much  advance,  although  it  has  from  time  to  time 
had  strong  supporters.  Herrgott*  attributes  some  cases  to  such  a 
cause,  while  Stroganoff  t  strongly  upholds  the  view  that  eclampsia 
is  a  contagious  disease. 

The  objections  to  a  bacterial  theory  are  that  eclampsia  is  never 
an  epidemic  disease ;  that  it  is  more  common  amongst  primiparae 
than  amongst  multipara?  ;  and  that  no  bacterium  constant  in  its 
presence  or  capable  of  reproducing  the  disease  has  been  isolated. 

The  Neurotic  Theory.— The  neurotic  theory  attributes  eclampsia 
to  a  heightened  irritability  of  the  nerve-centres,  or  to  excessively 
strong  stimuli  from  the  uterus  (eclampsia  reflectorica) .  This 
theory  receives  support  from  cases  which  show  the  influence  of 
heredity  or  of  a  neurotic  disposition,  and  helps  to  explain  those 
cases  in  which  no  evidence  of  renal  disease  can  be  found. 
Ribemont  -  Dessaignes  and  Gueniot  bring  it  to  the  assistance 
of  the  renal  auto-intoxication  theory,  as  furnishing  the  necessary 
predisposing  factor,  by  the  concurrence  of  which,  poisoning  by 
urinary  extractives  can  cause  the  onset  of  eclamptic  attacks. 

Stumpf's  Theory. — Stumpf's  theory, X  that  the  fits  are  due  to  the 
circulation  in  the  blood  of  some  poison  produced  by  an  abnormal 
decomposition  in  either  mother  or  child,  has  received  a  certain 
amount  of  revived  support  of  late.  Stumpf  considered  that,  '  under 
abnormal  processes  of  decomposition,  a  substance  free  from 
nitrogen,  toxic  in  its  action,  perhaps  acetone,  or  a  body  re- 
sembling it  which  reacts  to  the  same  tests,  may  be  formed.  That 
this  body  produces  by  its  excretion  an  irritation  of  the  kidneys 

*  Annates  de  Gyn.,  1893,  xxxix. ,  1-8,  109-120. 

t  Centralb.f.  Gyn.,  1901,  1309-1312. 

%  Trans.  First  German  Gyncecotog.  Congress  in  Munich,  Leipzig,  1886,  pp.  191- 
173  ;  and  Milnchener  Med.  Wochen.,  1887,  Ncs.  35  and  36,  pp.  671-674  and 
693-695- 


THE  CAUSATION  OF  ECLAMPSIA  603 

which  may  eventually  lead  to  nephritis,  has  a  destructive  effect 
upon  the  colouring  matter  of  the  blood,  greatly  alters  the  activity 
of  the  liver  cells,  causes  sugar  to  appear  in  the  urine,  and 
produces  the  destruction  of  the  parenchyma  of  the  liver  leading  to 
acute  yellow  atrophy  of  the  organ  with  the  formation  of  tyrosin 
and  leucin,  and  induces  coma  and  convulsions  from  an  irritation 
of  the  brain.'  Fehling*  has  lent  support  to  this  theory.  Accord- 
ing to  him,  it  may  be  that  the  metabolism  of  the  foetus  and  the 
transference  of  the  final  products  into  the  maternal  circulation 
are  of  more  importance  than  has  hitherto  been  supposed.  The 
nephritis  of  pregnancy  is,  he  thinks,  most  probably  not  the  cause 
of  eclampsia,  but  the  first  sign  of  intoxication,  of  which  eclampsia, 
if  it  supervenes,  may  be  the  second.  The  fact  that  the  foetus 
almost  always  dies  in  these  cases,  the  predisposition  to  eclampsia 
in  the  case  of  multiple  pregnancy,  and  the  improvement  in  the 
prognosis  for  the  mother  which  the  death  of  the  foetus  affords,  are 
all  in  favour  of  the  supposition  of  the  cause  of  eclampsia  being 
produced  in  the  foetus.  Schmorlf  ascribes  eclampsia  to  an  in- 
toxication by  coagulation-producing  ferments  which  originate  in 
the  placenta,  and  which  cause  thrombi  in  the  various  organs. 
As  we  have  already  pointed  out,  these  thrombi  are  probably  due  to 
syncytial  emboli,  and  possess  no  pathological  importance. 

The  Urinaemic  Theory. — This  theory,  which  has  received  con- 
siderable support,  J  attributes  the  onset  of  fits  to  the  retention  of 
the  normal  urinary  toxins  owing  to  the  failure  of  function  on  the 
part  of  the  kidney,  and  so  makes  them  the  symptom  of  urinaemia. 
To  such  a  poisoning,  all  the  constituents  of  the  urine  would  con- 
tribute. Coincidently  with  the  onset  of  the  premonitory  symptoms 
of  eclampsia,  the  urine  has  been  found  to  diminish  in  toxicity. 
It  also  diminishes  in  amount,  so  that  there  must  be  a  consequent 
retention  of  the  normal  urinary  toxins  in  the  body.  Coincidently 
with  the  recovery  of  the  patient,  the  toxicity  of  the  urine  increases, 
as  also  does  the  total  amount  of  urine  passed.  The  fact  that 
eclampsia  so  frequently  occurs  in  patients  suffering  from  renal 
disease,  and  that  it  rarely  or  never  occurs  when  this  condition  has 
been  so  treated  that  urinary  suppression  does  not  occur,  are 
strong  points  in  favour  of  this  theory  ;  while,  on  the  other  hand, 
the  latter  furnishes  no  explanation  of  the  morbid  appearances 
which  are  met  with  in  the  liver  ;  nor  does  it  account  for  those 
cases — about  five  per  cent,  of  the  entire  number — in  which 
there  is  no  evidence  of  renal  disease.     Recent  investigations^  go 

*  Volkmann's  Sammlung  Klin.  Vortrage,  N.F. ,  1899,  No.  248,  and  Verh.  der 
Deutschen  Gesel.  f.  Gyn.,  1901,  239-261. 

f  'Path.  Anat.  Untersuchungen  iiber  Puerperal-eklampsie,'  Leipzig,  1893, 
and  Archiv  f.  Gyn.,  1902,  Ixv.,  504-529. 

I  Bouchard,  Peter,  Schottin,  and  others. 

§  Forchheimer  and  Stewart,  'On  the  Toxicity  of  the  Urine,'  Amer.  Journ. 
of  Med.  Sciences,  September,  1899,  pp.  297-303 ;  and  Schumacher,  '  Exper. 
Beitrage  zur  Eklampsie-frage,'  Hegar's  Beitrdge  zur  Geb.  und  Gyn.,  1901, 
v.  257-309. 


604  THE  PATHOLOGY  OF  PREGNANCY 

to  show  that  the  toxicity  of  eclamptic  urine  has  been  over- 
estimated, and  that  the  bad  effects  that  followed  its  injection 
into  animals  were  really  due  to  its  contamination  by  micro- 
organisms. 

Bouchard's  Theory. — Bouchard's  theory* — the  so-called  auto- 
intoxication theory — though  that  term  will  also  apply  to  the  last- 
attributes  eclampsia,  not  only  to  a  failure  of  function  of  the  kidneys, 
but  also  of  the  liver.  As  a  result  of  this  failure,  intoxication  occurs, 
not  only  from  urinary  extractives,  but  also  from  biliary  substances 
which  remain  in  the  blood,  and  from  toxins  which  are  no  longer 
destroyed  in  the  liver.  Auvard  and  Rivierei  add  to  this  theory 
the  effects  of  the  failure  of  elimination  in  the  skin  and  lungs, 
while  Bouffe  de  Saint-BlaiseJ  considers  the  haemorrhagic  infarcts 
of  the  liver  as  the  pathognomonic  lesion  of  eclampsia,  to  which 
even  the  convulsions  themselves  are  of  secondary  importance. 
The  cause  of  this  lesion,  he  thinks,  may  be  found  in  some 
chemical  or  septic  toxin  which  is  formed  in  the  intestine,  and 
is  brought  to  the  liver  by  the  blood.  There  can  be  no  doubt 
that  hepatic  as  well  as  renal  incompetence  plays  a  certain  part  in 
the  pathology  of  eclampsia,  but  whether  this  incompetence  is 
primary  or  secondary  is  extremely  doubtful. 

Perhaps  the  most  recent  theory  that  has  been  brought  forward 
is  that  of  Nicholson,  who  attributes  eclampsia  primarily  to 
defective  action  of  the  thyroid  gland,  whereby  the  normal  amount 
of  thyroid  juice  is  not  set  free.  The  action  of  iodothyrin — the 
active  principle  of  the  thyroid  juice — has  been  shown  to  be  the 
opposite  of  that  of  the  internal  secretion  of  the  supra-renal  glands, 
and  that  whereas  the  latter  tends  to  raise  the  blood-pressure  and 
to  contract  the  arterioles,  the  former  tends  to  lower  the  blood- 
pressure  and  to  dilate  the  arterioles.  Nicholson  considers  that 
these  secretions  normally  counter-balance  one  another,  and  that  it 
is  probable  that  if  the  iodothyrin  is  diminished,  the  secretion  of  the 
supra-renal  glands  produces  an  intense  constriction  of  the  renal 
arterioles,  and  so  diminishes  the  secretion  of  urine ;  further,  that 
proteids  which  should  have  been  modified  by  the  action  of 
iodothyrin,  come  to  the  liver  unchanged,  and  so  throw  extra  work 
on  that  organ.  Thus  a  failure  of  elimination  and  an  accumula- 
tion of  toxins  result,  and  lead  up  to  the  onset  of  eclamptic  con- 
vulsions. 

So  far  as  we  can  see  at  present,  it  appears  manifest  that 
auto-intoxication  has  much  to  do  with  the  onset  of  eclampsia. 
How  exactly  the  intoxication  arises  cannot  be  definitely  laid 
down,  but  it  is  more  than  probable  that  it  may  occur  in  one  or 
more  of  several  different  ways.     Failure  in  one  eliminatory  organ 

*  Legons  sur  l'Auto-intoxication,  Paris,  1887. 
■j-  '  Pathogenie  et  Traitement  de  l'feclampsie,'  Paris,  1889. 
$  Annates  de  Gyn.  et  d'Obst.,  1891,  xxxv.  48;   i<5g8,  1.  342-373;  1900,  liv., 
76,  77- 


THE  CAUSATION  OF  ECLAMPSIA  605 

will  lead  so  quickly  in  turn  to  failure  in  another,  that  it  is  difficult 
to  ascertain  which  organ  was  the  first  to  fail,  and  it  is  equally 
impossible  to  say  with  accuracy  whether  the  presence  of  toxic 
substances  in  the  organism  is  the  cause  or  the  result  of  the 
eliminatory  failure.  For  this  reason,  it  seems  to  us  to  be  an  easy 
matter  to  multiply  apparent  primary  causes  of  the  onset  of 
eclamptic  fits,  but  to  be  impossible  to  establish  anything  in  the 
nature  of  a  constant  primary  cause.  This  is  but  another  way 
of  saying  that  there  is  no  such  thing  as  a  specific  disease 
eclampsia,  but  that  eclamptic  fits  are  the  symptom  of  many 
pathological  conditions  found  in  association  with  pregnancy, 
the  most  important,  perhaps,  of  which  is  auto-intoxication  in 
some  form. 

It,  therefore,  seems  most  rational  in  the  present  state  of  our 
knowledge  to  consider  eclampsia,  not  as  a  specific  disease  the 
result  of  one  definite  condition,  be  it  of  the  liver,  or  of  the  kidney, 
or  of  the  higher  centres,  but  rather  as  a  symptomatic  condition, 
the  result  of  direct  over-stimulation  of  the  nerve-centres  by 
toxic  substances  circulating  in  the  blood,  or  of  their  reflex 
over-stimulation  by  peripheral  irritation  from  the  genital  tract. 
In  each  patient,  the  nature  of  the  toxin  or  of  the  peripheral 
irritant  may  differ,  and  with  it  the  special  symptoms  of  the  case, 
but,  in  each,  the  pathognomonic  symptom  will  be  the  occurrence 
of  convulsive  attacks.  Looking  at  the  origin  of  eclampsia  in  this 
light,  we  find  that  its  causes  can  be  classified  in  general  terms  in 
the  following  manner  : — 

I.  The  direct  stimulation  of  the  nerve-centres  by  toxic  substances 
circulating  in  the  blood  owing  to — 

(1)  The  accumulation  of  normal  toxins  in  the  blood  from 

failure  of  the  renal,  hepatic,  or  intestinal  eliminatory 
functions,  due  to  pre-existing  disease  of  these  organs. 

(2)  The  excessive  formation  of  normal  toxins,  or  the  forma- 

tion of  abnormal  toxins,  either  in  the  mother  or  the 
foetus,  which  in  their  process  of  excretion  through  the 
kidneys  cause  nephritis,  and  so  a  diminished  renal 
function,  and  so  a  further  increased  amount  of  toxins 
in  the  blood. 

II.  The  reflex  stimulation  of  the  nerve-centres,  due  to — 

(1)  Their  over-excitability  to  normal  stimuli,  as  in  the  case 

of  hysterical  patients  or  epileptics. 

(2)  Their  over-irritation  by  excessive  stimuli,  as  in  the  case 

of  obstructed  labour,  very  painful  labour  pains,  very 

old  or  very  young  primiparae. 
Time  of  Onset. — An  eclamptic  fit  rarely  occurs  prior  to  the  sixth 
month,  or  after  the  fifth  day  of  the  puerperium,  and  within  these 
limits  it  may  occur  at  any  tifne  either  during  pregnancy,  labour, 
or  the  puerperium.  The  following  list  shows  the  date  at  which 
one  hundred  cases  collected  by  Tarnier  and  by  Bar  occurred  : — 
During  the  fifth  month,  1  case  ;  sixth  month,  8  cases  ;  seventh 


606  THE  PATHOLOGY  OF  PREGNANCY 

month,    15  cases;   eighth  month,  33    cases;   eighth    and   a  half 
month,  36  cases ;  and  ninth  month,  7  cases. 

The  relative  frequency  with  which  the  fits  commence  during 
pregnancy,  labour,  or  the  puerperium,  as  shown  by  the  aggrega- 
tion of  various  Continental  and  American  statistics,*  is  as 
follows  : — During  pregnancy,  36*12  per  cent.  ;  during  labour, 
48*48  per  cent.  ;  and  during  the  puerperium,  i5'4  per  cent.  It 
is,  however,  probable  that  many  cases,  which  actually  started 
during  pregnancy,  have  been  counted  as  starting  during  labour, 
owing  to  uterino  contractions  having  commenced  at  the  time  the 
case  first  came  under  observation,  and  that  in  reality  the  greater 
number  of  cases  commence  during  pregnancy. 

Symptoms. — The  symptoms  of  eclampsia  must  be  considered 
two  under  heads  prodromal  symptoms,  actual  symptoms. 

Prodromal  Symptoms.  —  The  first  prodromal  symptom  of 
eclampsia  may  be  said  to  show  itself  the  moment  a  pregnant 
woman  passes  urine  containing  albumin,  if  previously  her  urine 
was  healthy.  In  this  connection,  the  following  rule  may  be 
given: — It  is  advisable  to  examine  the  urine  of  every  pregnant 
woman  during  the  sixth  and  seventh  month,  and  to  ascertain  the 
amount  passed  in  twenty-four  hours.  It  is  necessary  to  do  so  if 
from  her  history  or  appearance  we  have  any  grounds  for 
supposing  that  she  may  be  suffering  from  albuminuria.  The 
remaining  prodromal  symptoms  of  eclampsia  occur  a  short  time 
before  the  onset  of  the  fits,  and  their  early  recognition  is  a  matter 
of  necessity,  as  by  so  doing  it  is  possible  in  many  cases  to  com- 
pletely ward  off  the  threatened  attack.  They  consist  in  complete 
or  partial,  temporary  or  permanent,  loss  of  vision,  flashes  of  light 
before  the  eyes,  vertigo,  headache,  drowsiness,  mental  depression, 
nausea,  constipation,  and  epigastric  pain.  Coincidently  with  the 
foregoing,  the  amount  of  urine  passed  is,  as  a  rule,  markedly 
diminished,  and  the  amount  of  albumin  in  it  increased. 

Actual  Symptoms. — The  actual  symptoms  commence  with  the 
onset  of  the  fits.  A  fit  lasts  from  one  to  one  and  a  half  minutes, 
and  consists  of  three  stages — a  preliminary  stage,  a  tonic  stage, 
and  a  clonic  stage,  followed  by  a  varying  period  of  coma. 

The  preliminary  stage  lasts  from  a  half  to  one  minute.  It 
consists  of  various  convulsive  movements  of  the  head  and  facial 
muscles.  The  eyelids  twitch  vigorously,  the  eyeballs  are  deviated 
to  one  or  other  side  and  upwards,  the  nostrils  quiver,  and  spasms 
of  the  muscles  of  respiration  occur.  The  tonic  stage  then 
commences  and  lasts  from  fifteen  to  twenty  seconds.  The  patient 
becomes  rigid, -the  head  thrown  backwards  and  to  one  or  other 
side,  and  the  trunk  in  a  position  of  opisthotonos.  Respiration  is 
arrested,  the  jaws  are  tightly  clenched,  and  the  tongue,  which  was 
protruded  in  the  preliminary  stage,  may  be  violently  bitten.  The 
clonic  stage  follows,  and  lasts  a  varying  period,  the  tonic  spasms 
passing  off  gradually,  and  being  replaced  by  sharp  rhythmical 
movements — the  patient '  works.'  Finally,  the  clonic  movements 
*  Olshausen,  Pinard,  Knapp,  Goldberg. 


THE  SYMPTOMS  OF  ECLAMPSIA  607 

cease,  respiration  returns,  and  the  patient  lies  in  a  condition  of 
deep  coma.  The  duration  of  the  coma  varies  according  to  the 
number  of  fits  which  the  patient  has  had.  At  first,  it  only  lasts 
for  a  few  minutes,  but,  as  the  number  of  fits  increase,  it  lasts  in 
the  intervals  between  them.  The  number  of  fits  vary  greatly. 
The  patient  may  only  have  one,  while  on  the  other  hand  as  many 
as  a  hundred  have  occurred.  They  may  pass  off  entirely  for  a 
time,  and  then  recur.  In  a  severe  case,  they  follow  one  another 
at  ever-shortening  intervals.  In  such  a  case,  the  heart's  action 
soon  becomes  affected,  and  is  frequent,  weak,  and  finally  inter- 
mittent. The  lungs  are  also  involved,  and  become  congested, 
partly  as  a  result  of  the  failure  of  the  heart,  and  partly  from  the 
irritation  caused  by  the  entrance  of  particles  of  food  and  mucus — 
'  deglutition  pneumonia.'  The  temperature,  which  at  first  was 
normal,  gradually  rises  as  the  fits  recur,  and  may  finally  reach  a 
height  of  1040  F.  Total  or  partial  loss  of  vision  is  also  of 
frequent  occurrence.  There  is  almost  complete  suppression  of 
urine  and  constipation. 

Diagnosis. — The  foregoing  description  of  an  eclamptic  attack  is 
the  description  of  a  typical  case,  and  it  must  be  borne  in  mind 
that  the  greatest  divergence  from  this  type  may  be  met  with,  and 
that  the  attack  may  assume  the  most  atypical  form.  For  this 
reason,  too  much  reliance  must  not  be  placed  on  the  form  of  the 
convulsion  in  making  a  diagnosis  of  the  nature  of  the  case.  More 
information  will  be  obtained  by  studying  the  prodromata,  the 
history,  and  the  attendant  symptoms. 

Eclampsia  must  be  distinguished  from  epilepsy,  hysteria, 
drunken  delirium  and  coma,  and  the  coma  and  convulsions  of 
meningeal  and  cerebral  disease.  As  a  general  rule,  it  may  be 
stated  that  every  form  of  convulsion  in  a  pregnant  woman  who  is 
suffering  from  renal  disease  should  be  regarded  as  eclamptic  in 
origin  until  the  reverse  is  proved.  Epilepsy  may  be  recognised 
by  the  history  of  former  attacks,  by  the  absence  of  the  usual 
eclamptic  prodromata,  by  the  initial  epileptic  aura,  by  the  sharp 
onset  of  the  convulsive  seizure,  and  by  the  usually  complete 
absence  of  all  renal  symptoms.  Hysteria  is  recognised  by  the 
extreme  irregularity  of  the  convulsion,  by  the  absence  of  respira- 
tory spasm,  of  all  actions  which  would  hurt  the  patient,  and  of 
loss  of  consciousness,  and  by  the  passage  of  large  quantities  of 
pale  urine.  Alcoholic  coma  and  delirium  may  be  suspected  from 
the  history  of  the  case,  and  the  spirituous  odour  of  the  breath.  It 
can  be  definitely  recognised,  as  it  gradually  passes  off,  and  does 
not  recur.  The  urine  also  is  probably  free  from  albumin.  The 
coma  and  convulsions  of  meningeal  and  cerebral  disease  may  be 
indistinguishable  from  those  of  eclampsia  if  the  history  of  the 
onset  of  the  case  cannot  be  obtained.  It  must  not  be  forgotten 
that  the  two  conditions  may  coexist,  as  cerebral  haemorrhage 
occasionally  occurs  in  the  course  of  eclampsia. 

Complications. — The  principal  complications  of  eclampsia,  if 
indeed  they  can  be  considered  as  such,  and  not  rather  as  integral 


6o8  THE  PATHOLOGY  OF  PREGNANCY 

parts  of  the  disease,  are  failure  of  the  heart  and  consequent  oedema 
of  the  lungs.  Cerebral  haemorrhage  may  occur  from  the  rupture 
of  a  vessel  during  a  fit,  or  even  after  the  fits  have  ceased.  Septic 
pneumonia  may  result  from  the  inspiration  of  foreign  bodies  into 
the  lungs. 

Treatment.- — -The  treatment  of  eclampsia  must  be  considered 
under  two  heads — prophylactic  treatment  and  curative  treatment. 

Prophylactic  Treatment. — Prophylactic  treatment  must  be 
adopted  in  the  case  of  every  pregnant  woman  who  has  persistent 
albuminuria,  especially  if  the  urine  also  contains  tube-casts.  Such 
treatment  must  be  carried  out  still  more  rigorously  if  any  of  the 
other  prodromata  of  eclampsia  appear.  The  importance  attributed 
to  prophylaxis  will  be  shown  by  the  following  opinions  : — '  When 
a  patient  suffering  from  albuminuria  has  been  on  milk  diet  for  a 
week,  she  almost  to  a  certainty  escapes  eclampsia'  (Tarnier). 
'  Eclampsia  occurs  almost  exclusively  in  women  whose  urine  has 
not  been  examined  during  pregnancy '  (Ribemont-Dessaignes). 
'  The  author  has  never  yet  seen  a  case  of  eclampsia  occur  amongst 
the  numerous  cases  of  kidney  of  pregnancy  where  this  method. 
(i.e.,  prophylactic  treatment)  has  been  adopted  during  pregnancy ' 
(Diihrssen). 

It  is  practically  impossible,  and  it  is  rarely  necessary,  to  enforce 
an  absolute  milk  diet  from  the  date  at  which  renal  disease  is  first 
recognised,  i.e.,  about  the  sixth  month,  to  the  end  of  pregnancy. 
It  will  usually  suffice  if  milk  and  other  fluids  are  made  to  take  a 
great  share  in  the  dietary.  In  addition,  fish,  white  meat,  eggs, 
and  vegetables  may  usually  be  allowed.  If  milk  diet  is  not 
essential,  the  due  regulation  of  the  eliminatory  functions  of  the 
body  is.  The  bowels  must  be  freely  moved  each  day,  the 
skin  must  be  encouraged  to  act  by  frequent  warm  baths,  and  the 
amount  of  urine  passed  daily  must  be  noted.  The  dietary  of  the 
patient  and  the  daily  amount  of  urine  should  be  in  direct  propor- 
tion to  one  another,  and  the  freer  the  action  of  the  kidneys  the 
more  liberal  may  be  the  dietary.  The  moment  the  former  show 
any  signs  of  failure,  the  latter  must  be  reduced  to  milk  alone,  to  be 
cautiously  made  again  more  varied  as  the  renal  action  improves. 

If  the  urine  diminishes  to  a  marked  extent,  and  any  of  the 
prodromal  symptoms  of  eclampsia  appear,  a  hydragogue  purgative 
must  be  at  once  administered.  At  the  same  time,  to  increase  the 
action  of  the  skin,  hot  baths  and  wet  packs  must  be  ordered,  and 
the  patient  kept  wrapped  in  blankets.  A  suitable  purgative  to 
administer  in  these  cases  consists  of  ten  grains  of  Calomel,  com- 
bined with  a  drachm  of  Pulv.  Jalapae  Co.,  and  followed,  if  neces- 
sary— as  is  sometimes  the  case,  by  an  enema  at  the  end  of  six  hours. 

Curative  Treatment. — The  curative  treatment  of  eclampsia  is 
directed  in  the  main  towards  two  principal  points— the  arrest  of 
the  fits,  and  the  staving  off  of  complications. 


THE  TREATMENT  OF  ECLAMPSIA  609 

The  fits  must  be  checked  at  the  earliest  possible  moment,  as 
each  successive  attack  leaves  the  patient  more  liable  to  fall  a 
victim  to  the  complications  of  a  failing  heart  and  oedema  of  the 
lungs.  There  are  three  ways  of  attaining,  or  of  endeavouring  to 
attain,  this  end : — By  administering  sedatives,  by  removing  toxic 
substances  from  the  blood  and  tissues,  and  by  emptying  the 
uterus. 

By  Administering  Sedatives. — There  are  two  distinct  lines  of 
treatment  which  fall  under  this  head — the  chloral  and  chloroform 
treatment,  and  the  morphia  treatment. 

The  chloral  and  chloroform  treatment  consists  in  administering, 
upon  the  onset  of  an  attack,  thirty  grains  of  chloral  hydrate  by  the 
rectum,  and  repeating  it  every  two  hours  until  the  fits  cease.  Up 
to  three  and  a  half  drachms  may  be  given  within  twenty-four  hours, 
but  not  more.  The  inhalation  of  chloroform  is  commenced  as  soon 
as  any  sign  of  the  onset  of  a  fit  is  noticed,  and  is  continued  until 
the  fit  is  over.  The  great  objection  to  this  line  of  treatment  is 
that  both  chloroform  and  chloral  exert  a  depressant  effect  upon 
the  heart,  and  consequently  tend  to  favour  the  occurrence  of 
heart  failure. 

The  morphia  line  of  treatment  was  first  introduced  by  Veit.:|; 
It  is  the  treatment  which  the  writer  recommends,  as  he  considers 
it  superior  to  the  chloral  and  chloroform  treatment.  It  consists 
in  the  administration  of  half  a  grain  of  morphia  hypodermically 
as  soon  as  a  fit  occurs.  A  quarter  of  a  grain  is  then  administered 
every  two  hours  until  the  fits  cease,  but  not  more  than  three  grains 
are  given  in  twenty-four  hours.  Eclamptic  patients  readily  tolerate 
such  large  doses.  Morphia  will  check  convulsions  quite  as  rapidly 
as  chloroform,  as  statistics  show,  while  at  the  same  time  it  has 
not  the  same  depressant  effect  upon  the  heart.  It  in  addition 
relaxes  the  bloodvessels,  and  so  lowers  the  blood-pressure,  and 
temporarily  arrests  the  metabolic  processes  of  the  body. 

By  Removing  Toxic  Substances  from  the  Blood  and  Tissues. — 
The  rapid  removal  of  toxic  substances  from  the  organism  of  the 
patient  is  a  matter  of  the  greatest  importance,  inasmuch  as  it  is 
apparent  that  even  if  these  substances  are  not  the  actual  cause  of 
the  convulsions,  they  are  always  present  in  large  quantities,  and 
their  removal  is  attended  by  almost  immediate  improvement.  Their 
removal  is  effected  in  the  main  by  promoting  the  excretory  func- 
tions of  the  body,  and  with  this  object  cathartic  purgatives  are 
administered.  The  calomel  and  jalap  powder,  as  recommended 
above,  if  the  patient  is  conscious,  is  the  best  purgative.  If,  how- 
ever, she  is  comatose,  it  is  useless  to  place  bulky  medicine  in  her 
mouth,  as  it  would  not  be  swallowed.  In  such  a  case  two  minims 
of  croton  oil  made  into  a  bolus  with  a  little  butter,  and  placed  as 
far  back  upon  the  tongue  as  possible,  may  reach  the  stomach. 
A  soap  and  water,  or  castor  oil  and  turpentine,  enema  should  also 
be  given  if  necessary.  At  the  same  time,  the  action  of  the  skin 
*  '  Ueber  die  Behandlung  der  Eklampsie,'  Ruge's  Festschrift,  1896,  101-120. 

39 


610  THE  PATHOLOGY  OF  PREGNANCY 

must  be  encouraged,  and  with  this  end  in  view,  the  patient  is  kept 
in  blankets,  and  hot  baths  administered  if  possible.  If  the  latter 
are  not  possible,  a  wet-pack  or  hot-air  bath  may  be  tried  instead. 
The  amount  of  urine  excreted  may  be  increased  by  applying  hot 
stupes  over  the  kidneys,  while  abundance  of  fluid  by  the  mouth 
— if  the  patient  is  conscious — will  also  be  of  use.  Diuresis,  or, 
at  any  rate,  the  dilution  of  the  poison,  can  also  be  obtained 
by  intravenous  or  subcutaneous  injections  of  saline  solution. 

Jardine,:;:  of  Glasgow,  is  largely  responsible  for  the  introduction 
of  saline  infusions  in  eclampsia.  He  adopts  the  practice  as 
a  routine  in  all  cases,  and  has  no  hesitation  in  saying  that  it 
has  given  him  much  better  results  than  any  other  method.  He 
uses  a  solution  of  thirty  grains  of  acetate  of  soda  to  the  pint  of 
water,  and  injects  up  to  three  pints,  according  to  the  nature  of  the 
case,  into  the  cellular  tissue,  preferably  beneath  the  breast.  The 
injection  is  repeated  if  it  is  thought  necessary.  It  may  be  men- 
tioned that  Jardine  condemns  the  use  of  morphia,  on  the  grounds 
that  it  diminishes  the  amount  of  urine  excreted,  and  that  death 
from  poisoning  has  followed  its  use. 

In  conjunction  with  saline  injections,  venesection,  to  the  amount 
of  seventeen  ounces,  has  been  recommended,  with  the  object  of 
removing  some  of  the  toxin-laden  blood,  which  is  then  replaced  by 
the  saline  fluid.  Whatever  may  be  the  value  of  venesection  in 
attaining  this  object,  it  is  undoubtedly  of  use  in  those  cases  in 
which  there  is  marked  engorgement  of  the  right  heart  and 
pulmonary  circulation  (Fehling). 

Nicholson,  in  accordance  with  his  view  that  eclampsia  is  largely 
due  to  the  deficiency  of  thyroid  secretion,  recommends  the 
administration  of  thyroid  extract,  both  as  a  prophylactic  measure 
and  as  active  treatment.  As  a  prophylactic,  he  administers  the 
extract  in  five-grain  doses  night  and  morning ;  while  if  eclamptic 
fits  have  occurred,  he  considers  that  the  action  of  the  extract  given 
in  this  manner  is  not  sufficiently  active,  and  consequently  recom- 
mends the  hypodermic  injection  of  ten  to  fifteen  minims  of  liquor 
thyroidea  repeated  every  hour  or  two  until  signs  of  improvement 
result.  He,  however,  considers  that  morphia  should  also  be  used 
in  almost  the  same  manner  as  that  we  have  already  described. 
If  thyroid  inadequacy  can  be  shown  to  exist  during  the  onset  of 
eclamptic  fits,  then  this  treatment  is  a  sound  one,  but  there  is  not 
as  yet  sufficient  evidence  on  this  point. 

By  Emptying  the  Uterus. — If  it  is  determined  to  empty  the 
uterus  before  the  onset  of  labour,  the  os  is  dilated  by  Bossi's  or 
Frommer's  dilator,  or  by  deep  incisions  (Diihrssen).  If  the 
foetus  is  dead,  its  extraction  may  be  facilitated  by  performing 
craniotomy ;  if  it  is  alive,  it  must  be  delivered  by  the  forceps  or 
by  version  and  extraction. 

The  question  of  the  advisability  or  otherwise  of  immediately 
emptying  the  uterus  in  all  cases  of  eclampsia  has  for  long  been 
*   '  Clinical  Obstetrics,'  1903,  p.  364. 


THE  TREATMENT  OF  ECLAMPSIA  611 

an  obstetrical  moot-point,  on  which  opinions  have  been  and  are 
likely  to  be  divided.  Many  obstetricians,  who  were  at  the  same 
time  expert  operators,  have  obtained  good  results  by  adopting 
this  practice.  Diihrssen  in  particular,  who  habitually  dilated  the 
uterine  orifice  by  deep  incisions  and  extracted  the  foetus,  ob- 
tained results  which  enabled  him  to  say  that  his  practice  was 
a  certain  method  of  checking  the  fits. 

More  recently,  Bumm*  has  published  results  which  to  a  con- 
siderable extent  support  Diihrssen's  contentions.  From  1882  to 
1895,  ne  adopted  treatment  with  narcotics  in  forty-seven  cases, 
using  chloroform  in  twelve,  morphia  in  thirty-one,  chloral  hydrate 
with  morphia  in  four.  There  were  fifteen  deaths,  or  a  mortality 
of  30  per  cent.,  and  the  results  were  apparently  identical  in  the 
case  of  the  different  narcotics.  From  1895  to  1900,  he  treated 
forty-three  cases  by  morphia,  with  the  addition  of  the  free  use  of 
diaphoretics,  and  in  seven  of  the  worst  cases  venesection  and 
transfusion.  There  were  thirteen  deaths,  or  a  mortality  of  30  per 
cent.  From  1901  to  1903,  the  uterus  was  emptied  at  once — i.e., 
in  the  case  of  patients  in  the  clinic  after  their  first  or  second 
fit,  and  in  others  within  at  most  half  an  hour  of  their  admission. 
There  were  twenty-five  cases,  including  one  abdominal  and  seven 
vaginal  Caesarean  sections,  seven  forceps  deliveries,  six  cases  of 
podalic  version  and  extraction,  one  delivery  by  the  presenting 
foot,  and  one  perforation  of  a  dead  child.  There  were  three  deaths, 
a  mortality  of  12  per  cent.  The  statistics  collected  by  Herman  f 
do  not,  however,  furnish  so  favourable  evidence  in  support  of 
immediate  delivery.  They  show  that  the  percentage  mortality 
after  operative  delivery  was  25-5,  while  in  the  case  of  those 
patients  who  were  not  delivered  by  operation  it  was  only  20*8. 
There  is,  however,  but  little  doubt  that  if  immediate  delivery 
is  to  give  good  results  it  must  be  adopted  at  once,  and  not 
as  a  dernier  ressort.  For  this  reason,  we  do  not  attach  the 
same  value  to  Herman's  statistics  that  we  should  if  they  applied 
to  cases  of  true  immediate  delivery,  and  not  merely  to  all  cases  in 
which  the  uterus  was  emptied.  Of  late,  a  considerable  stimulus 
has  been  given  to  the  practice  of  immediate  delivery  by  the  intro- 
duction of  Bossi's  dilator  and  its  modifications,  and  the  publica- 
tion of  the  successful  results  obtained  by  its  means  by  Leopold 
and  others.  Leopold^  was  able  to  report  twelve  cases  in  which 
by  the  use  of  Bossi's  dilator  the  os  uteri  was  sufficiently  dilated  in 
from  twenty  to  thirty  minutes  to  allow  the  forceps  to  be  applied 
without  laceration,  and  the  foetus  to  be  delivered  without  com- 
plications.    All  the  patients  lived. 

At  the  Rotunda  Hospital  in  the  past,  narcotic  treatment  has 
been  almost  entirely  adopted.  From  1889  to  1893,  twenty-six 
patients  were  treated  by  the  chloral  and  chloroform  method,  with 

*  Munchener  Med.  Wochens.,  1903,  No.  21. 

•f-  Trans.  Med.  Society  of  London,  vol.  xxv.,  p.  234. 

j  Ceniralb.f.  Gyn.,  1902,  May  10. 

39—2 


612  THE  PATHOLOGY  OF  PREGNANCY 

seven  deaths,  or  a  percentage  mortality  of  twenty -seven.  From 
1893  to  1903,  thirty  patients  were  treated  by  the  "morphia  method, 
with  seven  deaths,  or  a  percentage  mortality  of  twenty-three. 
The  results  by  both  methods  are  better  than  those  obtained  by 
Bumm,  and  are  slightly  in  favour  of  the  morphia  treatment. 

In  the  present  state  of  our  knowledge,  it  is  as  unprofitable  to 
endeavour  to  dogmatise  on  the  correct  treatment  of  eclampsia  as 
on  its  true  aetiology.  The  results  which  are  obtained  by  different 
lines  of  treatment  are  influenced  to  a  great  extent  by  chance — 
that  is  to  say,  by  the  nature  of  the  particular  series  of  cases  the 
obstetrician  happened  to  meet.  When  Veit  first  introduced  the 
morphia  treatment  he-was  able  to  report  a  series  of  cases  without  a 
death,  and  similarly  when  Leopold  introduced  the  use  of  Bossi's 
dilator  he  reported  twelve  cases  without  a  death.  On  the  other 
hand,  Bumm  experienced  a  mortality  of  thirty  per  cent,  from  the 
morphia  treatment,  and  doubtless  other  obstetricians  have  been 
equally  unfortunate  with  Bossi's  dilator.  As  we  have  en- 
deavoured to  point  out  already,  eclamptic  convulsions  are  not 
a  specific  disease,  but  a  symptom  of  many  pathological  con- 
ditions. We  believe  that  the  most  successful  results  will  be 
obtained  by  the  man  who  most  correctly  and  most  rapidly  ascer- 
tains the  cause  of  the  convulsions  in  the  particular  case  he  is 
treating,  and  who  varies  his  treatment  to  suit  the  cause. 

There  can  be  little  doubt  that  the  majority  of  cases  are  due 
to  an  auto-intoxication,  and  we  have  laid  down  the  general  prin- 
ciples on  which  this  must  be  treated.  The  question  as  to  how 
the  convulsions  are  to  be  checked  during  the  removal  of  the 
toxins  from  the  system  is  a  much  more  difficult  one.  It  is  too 
soon  to  lay  down  the  respective  merits  of  treatment  by  narcotics 
or  by  emptying  the  uterus.  The  specialist  does  not  require 
advice,  as  he  will  adopt  the  method  from  which  he  has  obtained 
the  best  results,  until  one  which  furnishes  better  is  clearly 
demonstrated.  The  general  practitioner,  however,  must  be 
advised,  and  we  recommend  that,  if  he  has  not  had  a  con- 
siderable experience  of  operative  obstetrics,  he  should  adopt 
the  morphia  treatment,  and  should  not  empty  the  uterus  until 
such  time  as  he  can  do  so  with  the  forceps  without  causing 
laceration  of  the  cervix.  If,  however,  the  morphia  treatment 
proves  unavailing,  the  uterus  should  be  emptied  by  incision  of 
the  cervix  and  forceps  extraction,  or  by  Bossi's  or  Frommer's 
dilator.  If,  on  the  other  hand,  he  is  an  expert  operator,  the 
results  which  have  been  obtained  by  Bossi's  dilator  are  such  as 
to  justify  him  in  resorting  to  it,  and  in  delivering  the  patient  as 
soon  as  possible  after  the  convulsions  have  commenced.  All  such 
operations  must  be  performed  under  deep  anaesthesia,  and  care 
must  be  taken  that  the  cervix  is  not  lacerated. 

The  complications  associated  with  eclampsia  can  to  a  great 
extent  be  avoided  by  means  of  intelligent  nursing,  and  by  paying 
the  greatest  attention  to  details.     While  the  patient  is  in  a  fit, 


THE  PROGNOSIS  OF  ECLAMPSIA 


6i3 


she  must  not  be  allowed  to  bite  her  tongue  or  otherwise  hurt 
herself.  Biting  of  the  tongue  is  a  common  accident.  Its  occur- 
rence can  be  prevented  by  the  use  of  a  gag  of  some  form  placed 
between  the  teeth  during  the  fit.  A  very  serviceable  gag  can  be 
rapidly  made  by  wrapping  a  towel  or  other  piece  of  cloth  round 
the  handle-end  of  a  spoon.  All  feeding  by  the  mouth  must  be 
stopped  while  the  patient  is  unconscious.  If  it  is  necessary  to 
administer  nourishment  while  she  is  in  this  condition,  nutrient 
enemata  must  be  given.  The  position  of  the  patient  must  be 
such  that  all  fluid  which  tends  to  collect  in  the  mouth  will  trickle 
out  at  the  side  of  it,  instead  of  running  down  into  the  lungs — - 
i.e.,  she  must  lie  upon  her  side,  and  not  upon  her  back.  If  the 
heart  becomes  weak  and  rapid,  digitalin  and  strychnine  may  be 
administered  hypodermically. 

Prognosis.  —  The  prognosis  for  both  mother  and  child  in 
eclampsia  is  bad,  especially  for  the  latter.  For  the  mother,  the 
prognosis  varies  according  to  the  time  at  which  the  fits  start. 
It  is  worst  when  they  commence  during  pregnancy  or  labour ; 
it  is  best  when  they  commence  during  the  puerperium.  The 
greater  the  number  of  fits  the  worse  the  prognosis.  As  a  rule, 
the  occurrence  of  ten  fits  constitutes  a  very  severe  case.  If 
the  child  dies,  the  maternal  prognosis  is  improved.  The 
amount  of  urine  passed  and  the  quantity  of  albumin  in  it,  the 
presence  or  absence  of  marked  constipation,  the  temperature,  and 
the  condition  of  the  heart  and  lungs,  are  also  important  guides. 

The  actual  rate  of  mortality  varies  very  considerably  both 
according  to  the  treatment  adopted  and  according  to  the  nature 
of  particular  groups  of  cases.  The  following  tables  give,  how- 
ever, a  fair  idea  of  the  relative  rate  of  mortality  when  the  con- 
vulsions occur  during  pregnancy,  labour,  and  puerperium  ;  in 
primiparae  or  in  multipara  ;  and  in  relation  to  the  number  of 
convulsive  attacks  : — ■ 


Time  of  Onset.* 

Primiparsg. 

Multiparas. 

Cases. 

Deaths. 

Cases. 

Deaths. 

In  pregnancy 
In  labour 
After  labour 

69 
60 

17  (24*3  per  cent.) 

18  (157  per  cent.) 
7  (11  "6  per  cent.) 

34 
3i 
16 

10  (29-4  per  cent.) 
7  (226  per  cent.) 
4  (25  6  per  cent.) 

Number  of  Attacks. f 

Cases. 

Number  of  Deaths. 

Mortality. 

Below  10 

152 

36 

23  6  per  cent. 

11  to  20 

62 

17 

27-4 

21  to  30 

24 

12 

50 

31  to  40 

17 

13 

76 

41  to  50 

5 

3 

60 

51  to  60 

4 

4 

100 

Lohlein. 


•j-  Schauta. 


CHAPTER  VI 
THE  INTRA-UTERINE  DEATH  OF  THE  FCETUS 

Frequency  —  ^Etiology ;  Pathological  Conditions  of  the  Mother  ;  of  the 
Father ;  of  the  Ovum  ;  Traumatic  Conditions ;  Unascertained  Causes — 
Symptoms  and  Diagnosis — Treatment. 

It  is  not  proposed  to  discuss  in  this  book  the  various  intra- 
uterine foetal  diseases  which  are  met  with.  They  are  numerous, 
and  hence  it  would  only  be  possible  to  devote  a  very  small  and 
insufficient  space  to  each.  Certain  of  them  produce  conditions 
which  interfere  with  the  mechanism  of  delivery,  and  these  will 
be  referred  to  when  treating  of  the  pathology  of  labour.  The 
remainder,  which  do  not  affect  pregnancy  save  in  some  cases  by 
bringing  about  the  death  of  the  foetus,  and  do  not  affect  labour 
at  all,  will  not  be  referred  to.  Their  description  more  properly 
belongs  to  a  work  on  ante-natal  pathology,  and  to  such  we  refer 
the  reader. 

In  the  present  chapter,  we  shall  deal  with  the  intra-uterine 
death  of  the  foetus,  its  causes,  and  the  treatment  necessary  to 
adopt  in  cases  in  which  its  occurrence  is  not  followed  by  the 
expulsion  of  the  ovum.  It  must  first  be  understood  that  in  this 
chapter  we  are  not  dealing  with  either  abortion  or  premature 
labour.  Either  of  these  conditions  may  be  the  result  if  the  intra- 
uterine death  of  the  foetus  or  may  be  quite  independent  of  such 
an  occurrence.  They  will  be  dealt  with  in  another  chapter. 
It  is  obvious,  however,  that  it  is  impossible  to  determine  prior 
to  the  sixth  month  whether  the  death  of  the  embryo  or  foetus,  as 
the  case  may  be,  is  preceded  or  accompanied  by  the  expulsion 
of  the  ovum,  save  in  a  few  instances,  where  the  embryo  has  almost 
or  entirely  disappeared.  This,  however,  need  not  affect  the 
general  tenor  of  the  present  chapter,  which  will  be  devoted  not 
to  the  premature  expulsion  of  the  ovum,  but  to  the  premature 
death  of  the  embryo  or  foetus,  whether  that  death  is  followed  by 
expulsion  or  not. 

Frequency. — For  the  reason  just  mentioned,  it  is  impossible  to 
tell  in  what  proportion  of  cases  the  intra-uterine  death  of  the 
foetus  occurs  prior  to  the  sixth  month  of  pregnancy.  In  all  prob- 
ability, the  proportion   of  cases  in  which  the  death  of  the  foetus 

614 


THE  INTRA-UTERINE  DEATH  OF  THE  FCETUS  615 

precedes  the  detachment  and  expulsion  of  the  ovum  is  considerable, 
as  in  many  cases  the  fcetus  has  entirely  disappeared,  or  is  only 
represented  by  a  disorganised  mass,  while,  in  other  cases,  it  has 
obviously  been  dead  for  some  time  prior  to  expulsion. 

The  proportion  of  cases  in  which  intra-uterine  death  occurs 
subsequent  to  the  twentieth  week  can  be  more  easily  ascer- 
tained, but  here  again  errors  may  occur  in  consequence  of  the 
difficulty  of  eliminating  cases  in  which  death  occurred  during 
delivery.  It  is  probable,  however,  that  all,  or  almost  all,  pre- 
mature infants,  which  are  born  dead,  were  dead  before  labour 
commenced,  as  the  difficulties  of  or  delay  in  labour  in  such 
cases  is  but  seldom  sufficient  to  cause  death.  Accordingly,  we 
may  include  in  the  number  of  intra-uterine  deaths,  all  cases  in 
which  an  immature  or  premature  infant  is  born  dead  after  the 
twentieth  week,  and  all  cases  in  which  a  full-term  infant  is  born 
in  such  a  condition  that  its  death  must  of  necessity  have  occurred 
prior  to  the  onset  of  labour — i.e.,  all  cases  of  macerated,  putrid, 
or  mummified  infants.  Of  16,654  infants  born  in  the  Rotunda 
Hospital  during  the  mastership  of  Collins,  801  may  be  con- 
sidered to  have  died  in  utero,  a  proportion  of  about  1  in  20.  The 
most  recent  statistics  of  the  hospital  are  somewhat  similar.  Of 
11,203  infants  born  in  the  hospital,  393  may  be  considered  to 
have  died  in  utero — a  proportion  of  1  in  28'5.  If  we  add  to  the 
number  of  dead-born  infants  half  the  number  of  abortions  which 
occurred  during  the  same  period,  a  number  which  will  not  unfairly 
represent  the  cases  in  which  the  death  of  the  embryo  was  the 
cause  of  the  abortion,  we  get  a  total  of  605  cases  of  intra-uterine 
death  in  11,098  pregnancies,  a  proportion  of  1  in  18*3.  This  is  a 
very  high  proportion,  and  represents  an  enormous  annual  loss  in 
the  total  potential  population.  It  emphasises  the  importance  of 
the  present  subject,  and  the  necessity  for  determining  the  cause 
of  such  deaths  and  the  means  of,  where  possible,  preventing  their 
occurrence. 

Aitiology. — The  different  causes  of  intra-uterine  death  may  be 
divided  into  the  following  groups  : — 

(1)  Pathological  conditions  of  the  mother. 

(2)  Pathological  conditions  of  the  father. 

(3)  Pathological  conditions  of  the  ovum  which  cannot  be 

definitely  allocated  to  one  or  other  of  the  foregoing 
classes. 

(4)  Traumatic  causes. 

(5)  Unascertained  causes. 

Pathological  Conditions  of  the  Mother.  —  The  commonest 
maternal  causes  of  fcetal  death  are  perhaps  syphilis,  renal  disease, 
endometritis,  acute  infectious  diseases,  and  high  temperature. 

Syphilis  is  perhaps  the  most  important  of  all  causes,  as  it  tends 
in  many  cases  to  destroy  not  alone  one  pregnancy,  but — unless 
treated — every  pregnancy.  Its  effects  are  more  marked  when  the 
woman   has   been    infected  prior    to   conception,   than    if  she   is 


616  THE  PATHOLOGY  OF  PREGNANCY 

infected  subsequently  to  conception.  If  conception  and  syphilis 
commence  together,  the  death  of  the  foetus  is  the  rule,  but  treat- 
ment is  more  potent  in  preventing  it  (Priestley*).  If  syphilis  is 
acquired  after  the  mid-period  of  pregnancy,  the  child  may  escape 
altogether.  Syphilis  may  bring  about  the  death  of  the  foetus  by 
causing  extensive  pathological  changes  in  the  foetus  itself,  or  in 
the  placenta. 

Chronic  renal  disease  is  a  common  cause  of  foetal  death  by 
causing  the  placental  alterations  which  have  been  alluded  to,  and 
so  interfering  with  the  oxygenation  of  the  foetal  blood  and  the 
supply  of  nutriment  to  the  foetus.  The  death  of  the  latter  may 
also  result,  in  cases  in  which  suppression  of  urine  and  uraemia 
have  supervened,  from  the  presence  of  toxins  in  the  maternal 
blood. 

Endometritis  most  usually  terminates  a  pregnancy  by  causing 
the  detachment  and  expulsion  of  the  ovum,  and  not  the  primary 
death  of  the  foetus.  It  may,  however,  in  many  cases  bring  about 
the  latter  by  causing  a  degeneration  of  the  ovum  and  the  con- 
dition known  as  a  blood- mole  or  apoplectic  ovum. 

Acute  infective  diseases  may  bring  about  the  death  of  the 
foetus  in  two  ways — either  by  the  lethal  effect  upon  the  foetus  of 
the  toxic  condition  of  the  maternal  blood,  or  by  the  elevation  of 
temperature  by  which  the  disease  is  accompanied.  Attempts  have 
been  made  to  prove  one  or  other  of  these  to  be  the  true 
cause  of  death,  but  it  appears  to  be  impossible  and  useless  to 
endeavour  to  distinguish  between  them.  There  is  no  doubt  that 
either  factor  in  itself  can  bring  about  the  death  of  the  foetus,  and 
the  particular  factor  which  does  so  in  any  given  case  will  depend 
upon  which  of  them  is  the  more  strongly-marked  characteristic 
of  the  disease  from  which  the  patient  is  suffering.  If  the  toxic 
condition  of  the  blood  is  more  marked  than  the  elevation  of  tem- 
perature, it  will  kill  the  foetus  before  the  latter  has  time  to  do  so, 
and  vice  versa. 

The  effects  of  elevation  of  temperature  upon  the  foetus  have 
been  summarised  as  follows  by  Runge,f  who  made  many  im- 
portant experiments  upon  animals  : — 

(i)  The  temperature  of  the  foetus  is  habitually  higher  than  that 
of  the  mother,  and  maintains  this  greater  height  when  the 
mother's  temperature  becomes  abnormal. 

(2)  The  foetus  dies  from  the  effects  of  increased  temperature 
before  such  increase  becomes  fatal  to  the  mother. 

(3)  The  temperature  of  the  mother,  if  only  raised  for  a  short 
period  to  106-7°  F.,  is  fatal  to  the  foetus. 

Among  the  rarer  maternal  causes  of  foetal  death  are  to  be  found 
the  following  : — 

(1)  Anaemia. — This  in  all  probability  causes  the  death  of  the 
foetus  by  diminishing  the  amount  of  nutriment  which  is  carried 
to  it  in  the  blood. 
*  '  The  Pathology  of  Intra-uterine  Death,'  p.  60.       f  Archiv  f.  Gyndk.,  1877. 


THE  INTRA-UTERINE  DEATH  OF  THE  FOETUS  617 

(2)  Phthisis. — This  probably  causes  the  death  of  the  foetus  in 
the  same  manner  as  does  anaemia. 

(3)  Diabetes.— Although  the  presence  of  a  small  amount  of 
sugar  in  the  urine  in  pregnancy  is  far  from  uncommon,  the 
association  of  true  diabetes  with  pregnancy  is  very  fatal  to  the 
foetus.  Matthews  Duncan*  recorded  nineteen  cases  of  pregnancy 
in  fourteen  diabetic  patients,  in  which  seven  of  the  infants  died  in 
utcvo,  after  reaching  prematurity,  and  two  more  died  a  few  hours 
after  birth.  The  manner  in  which  diabetes  brings  about  the  death 
of  the  foetus  is  not  very  clear,  but  it  is  probably  the  poisoning  of 
the  foetus  by  some  toxin  circulating  in  the  maternal  blood. 

(4)  Action  of  Certain  Poisons. — Lead-poisoning  is  particularly 
prone  to  cause  the  intra-uterine  death  of  the  foetus,  and  traces  of 
the  metal  are  said  to  have  been  found  in  such  cases  in  the  foetal 
kidneys  (Legrand).  Poisoning  by  arsenic,  savin,  carbon  monoxide 
and  dioxide  have  also  caused  foetal  death. 

(5)  Eclampsia. — The  intra-uterine  death  of  the  foetus  may 
almost  be  regarded  as  the  ride  in  eclampsia,  unless  the  foetus  is 
expelled  within  a  comparatively  short  period  of  the  onset  of  con- 
vulsions. The  cause  of  its  death  is  not  definitely  ascertained,  but 
is  most  probably  due  to  poisoning  by  the  excessive  quantity  of 
toxins  which  are  found  in  eclampsia  in  the  maternal  blood.  It 
may  also  be  due  in  some  cases  to  the  elevation  of  temperature 
which  occurs  during  the  convulsions  (Winckelf).  A  third 
suggestion  as  to  the  cause  of  death  is  that  the  oxygenation  of  the 
blood  is  interfered  with  during  the  convulsions,  and  that  the 
foetus  dies  of  asphyxia.  It  is  probable  that  the  actual  cause  of 
death  differs  in  different  cases,  and  that  it  depends  upon  which 
factor  is  the  first  to  become  sufficiently  intense  to  cause  death. 

Pathological  Conditions  of  the  Father. — The  most  important  of 
these  is  syphilis.  Syphilitic  disease  of  the  father  may  result  in 
the  transmission  of  infected  semen,  which  in  turn  produces  an 
ovum  affected  with  hereditary  syphilis.  If  the  syphilitic  lesions 
are  sufficiently  marked,  the  death  of  the  foetus  will  follow, 
even  though  there  has  been  no  apparent  infection  of  the  mother. 

Lead-poisoning  of  the  father  may  also  cause  the  intra-uterine 
death  of  the  foetus.  The  manner  in  which  it  does  so  is  most 
obscure,  but  clinically  the  fact  is  well  attested.  It  is  said  that 
tuberculosis  of  the  father  may  affect  the  ovum  in  a  somewhat 
similar  manner. 

Pathological  Conditions  of  the  Ovum. — In  this  group,  we  only 
include  such  pathological  conditions  as  cannot,  in  the  present 
state  of  our  knowledge,  be  definitely  attributed  to  either  maternal 
or  paternal  causes.  The  chief  of  these  are  vesicular  degenera- 
tion of  the  chorion,  abnormal  development  of  the  foetus,  and 
interruption  of  the  circulation  in  the  funis,  due  to  the  abnormal 
length  or  development  of  the  latter. 

Traumatic  Causes.  — Violent  blows  on  the  abdomen  of  the 
*  Trans.  Lond.  Obstet.  Soc,  1882.  f  '  Berichte  und  Studien.' 


6i8  THE  PATHOLOGY  OF  PREGNANCY 

mother  and  falls  may  cause  the  death  of  the  foetus  by  direct 
violence  or  by  causing  the  detachment  of  the  placenta. 

Unascertained  Causes. — It  is  not  uncommon  to  meet  with 
patients  with  whom  each  successive  foetus  dies  during  the  last 
two  or  three  months  of  pregnancy.  Such  cases  have  come  to  be 
spoken  of  as  cases  of  'habitual  death  of  the  foetus.'  In  many 
instances,  it  is  possible  to  determine  the  cause,  which  is  usually 
found  to  be  syphilis — maternal  or  paternal — or  perhaps  anaemia, 
tuberculosis,  or  inflammatory  conditions  of  the  uterus.  In  some 
cases,  however,  it  is  impossible  to  ascertain  any  cause  for  the 
death  of  the  foetus.  The  latter  dies  and  is  expelled,  but 
no  lesion  can  be  found  to  account  for  its  death.  It  would 
seem  as  if  the  mother  was  able  to  furnish  it  with  the  necessary 
amount  of  oxygen  and  nutriment  until  it  reached  a  certain  age, 
and  that  then  she  became  unable  to  do  so.  The  term  '  habitual 
death  of  the  foetus  '  should  be  kept  for  such  cases,  as  to  apply  it 
to  those  in  which  the  cause  of  death  is  known  is  inadvisable,  as  it 
tends  to  obscure  the  important  point — i.e.,  the  cause  of  the  recurrent 
deaths. 

Symptoms  and  Diagnosis. — If  the  embryo  or  foetus  dies,  the 
ovum  in  the  great  majority  of  cases  is  expelled.  In  some  cases, 
however,  it  is  retained,  and  then  the  condition  known  as  missed 
abortion  or  missed  labour  results.  In  missed  abortion,  the  retained 
ovum  usually  continues  to  receive  some  blood  -  supply  from 
the  uterus,  and  may  become  semi -organized,  and  form  what 
is  known  as  a  placental  or  fibrinous  polypus.  In  other  cases, 
saprophytic  bacteria  may  gain  entrance  to  the  uterus,  and  the 
retained  ovum  become  putrid.  In  cases  of  missed  labour,  in 
which  condition  we  have  to  deal  with  a  more  or  less  fully  formed 
foetus,  various  changes  may  occur  in  the  latter,  the  three  chief 
of  which  are  maceration,  mummification,  and  putrefaction,  and, 
according  as  one  or  other  of  them  occurs,  the  symptoms  will  vary. 

Maceration  is  dependent  on  three  conditions  : — (a)  Fluid  sur- 
roundings ;  (b)  warmth ;  (c)  an  absence  of  putrefactive  organ- 
isms. Under  these  conditions,  the  foetus  becomes  cedematous  and 
water-logged,  its  skin  peels  off  in  patches,  the  ligaments  of  the 
bones  soften  and  permit  abnormal  mobility,  and  the  viscera  become 
softenedand  cedematous,  and  undergo  a  fatty  degeneration.  The 
cord  in  some  cases  increases  in  size,  owing  to  infiltration  with 
liquor  amnii,  in  other  cases  it  becomes  flaccid  and  diminished 
in  size,  owing  to  disappearance  of  the  Whartonian  jelly.  The 
placenta  remains  longer  unaffected  than  the  foetus.  Finally, 
however,  it  atrophies,  and  becomes  of  a  greyish  colour,  as  a 
result  of  fatty  degeneration. 

It    is    difficult    to    determine,   by   the    degree    of    maceration 

present,  how  long  a  foetus  has  been  dead,  as  the  rapidity  with 

which  the  changes  take  place  probably   varies  considerably   in 

different  cases.     According   to  Ruge,   Lempereur,*   and  others, 

*  These  de  Paris,  1867. 


THE  INTRA-UTERINE  DEATH  OF  THE  FCETUS  619 

who  have  investigated  the  question,  there  is  very  little  change 
during  the  first  two  days  after  death,  save  an  increase  in  flaccidity, 
slight  discoloration  of  the  tissues,  and  a  slight  infiltration  of  the 
cord.  At  the  end  of  eight  days,  the  cranium  becomes  more 
flaccid  owing  to  softening  of  the  ligaments ;  the  skin  peels  off, 
and  blebs  form  over  various  parts  of  the  body  save  the  head. 
At  the  end  of  ten  days,  maceration  is  considerably  more  marked ; 
the  epidermis  is  stripping  even  off  the  face  ;  and  the  scalp  is 
infiltrated,  but  still  adherent.  To  the  foetus  at  this  stage,  the 
term  fains  sanguinolentus  was  given  by  Ruge.  It  is  difficult  to 
believe  that  in  some  cases  these  changes  are  not  produced  more 
rapidly,  as  it  is  not  uncommon  to  meet  a  considerable  degree  of 
maceration  in  an  infant  which,  according  to  the  history  of  the 
mother,  was  alive  twenty-four  hours  before.  The  gross  macro- 
scopical  changes  are  in  the  main  due  to  the  water-logging  of  the 
tissues,  and  the  rate  at  which  this  takes  place  must  largely  depend 
upon  the  amount  of  liquor  amnii  present  and  upon  the  intra- 
uterine pressure.  The  practical  importance  of  this  is  evident  in 
medico-legal  cases,  where  it  may  be  necessary  to  attempt  to  fix 
the  date  at  which  the  death  occurred.  In  such  cases,  an  opinion 
based  on  the  degree  of  maceration  should  be  most  guarded. 

Mummification  of  the  foetus  is  an  unusual  occurrence,  and  is 
akin  to  '  the  preserving  of  meat  in  brine.'  It  is  essentially  a 
drying-up  or  desiccative  change,  and  is  probably  associated  with 
a  comparative  absence  of  liquor  amnii.  The  foetus,  instead  of 
becoming  cedematous,  shrinks,  and  gives  up  the  water  in  its 
tissues.  This  change  is  particularly  prone  to  occur  in  the  case 
of  a  dead  twin.  In  such  cases,  the  living  twin  as  it  grows  may 
press  the  dead  one  against  the  uterine  wall,  thus  flattening  it  out 
and  producing  the  condition  known  as  fcetus  compresstts  or  papyvaceus. 

Putrefaction  of  the  fcetus  calls  for  no  special  remarks.  The 
changes  the  foetus  undergoes  are  akin  to  those  associated  with 
putrefaction  of  any  other  animal  tissue,  and  in  consequence  of 
them  gas  collects  in  the  uterus. 

The  symptoms  to  which  the  retention  of  a  dead  fcetus  gives 
rise  have  been  already  described  in  the  chapter  on  obstetrical 
diagnosis,  and  need  not  be  again  referred  to.  The  diagnosis  of 
this  condition  has  also  been  dealt  with  in  the  same  place. 

Treatment. — The  prophylaxis  of  intra-uterine  death  of  the  fcetus 
is  a  matter  of  considerable  importance,  especially  in  those  cases 
in  which  the  cause  of  the  condition  is  recurrent  and  affects  suc- 
cessive pregnancies.  As  the  treatment  proper  to  adopt  has  been 
described  already  in  all  cases  in  which  the  recurrent  death  of  the 
foetus  is  due  to  a  specific  and  ascertainable  cause — such  as 
syphilis,  renal  disease,  or  anaemia,  it  is  unnecessary  to  again  enter 
into  it ;  and  here  we  need  only  refer  to  those  cases  which  we 
have  mentioned  to  which  the  term  '  habitual  death  of  the  foetus ' 
is  by  preference  applied,  and  in  which  the  cause  of  death  is  still 
obscure. 


620  THE  PATHOLOGY  OF  PREGNANCY 

The  treatment  of  these  cases  has  been  in  the  past,  and  still 
is,  largely  governed  by  the  belief  that  the  cause  of  death  is 
to  be  found  in  an  inability  on  the  part  of  the  mother  to  afford 
the  foetus  sufficient  oxygen  or  nutriment  after  it  has  reached  a 
certain  stage  of  development.  Accordingly,  the  usual  treatment 
adopted  consists  in  inducing  labour  a  short  time  before  the  period 
of  pregnancy  at  which  the  foetus  habitually  dies.  This  treatment 
is,  of  course,  only  applicable  in  cases  in  which  the  foetus  habitually 
dies  after  it  has  become  viable,  that  is,  after  the  end  of  the  seventh 
month,  and  it  has  also  the  disadvantage  that,  though  the  foetus 
may  be  saved  temporarily  from  an  otherwise  impending  death,  it 
runs  considerable  risk  of  dying  after  its  birth  owing  to  its  prema- 
turity. Still,  in  some  cases,  success  has  been  attained,  and, 
consequently,  if  all  other  means  fail,  the  induction  of  premature 
labour  should  be  tried  as  a  last  resource. 

More  than  fifty  years  ago,  the  late  Sir  J.  Y.  Simpson  recom- 
mended the  administration  of  chlorate  of  potassium  in  these  cases, 
on  the  principle  that  it  would  give  up  its  oxygen  and  so  increase 
the  quantity  of  that  essential  element  in  the  maternal  blood,  and 
thus  allow  the  foetus  to  obtain  the  necessary  quantity  even  in  the 
case  of  a  seriously  degenerated  placenta.  This  effect  of  chlorate 
of  potassium  is,  however,  universally  denied,  as  the  drug  is 
excreted  unchanged  from  the  body.  Jardine*  of  Glasgow  has, 
however,  of  late  again  administered  the  drug  in  these  cases,  and 
with  apparently  beneficial  results.  One  case  which  he  records  is 
of  special  interest.  Of  eight  pregnancies,  five  terminated  in  mis- 
carriages, or  in  the  intra-uterine  death  of  the  foetus,  while  in  three 
the  foetus  was  born  alive  at  term.  In  the  five  fatal  pregnancies, 
no  treatment  was  adopted.  In  the  three  instances  in  which  the 
foetus  lived,  chlorate  of  potassium  was  administered  regularly 
during  the  course  of  pregnancy.  Jardine  administers  the  drug 
in  doses  of  ten  grains  three  times  a  day,  from  the  third  month 
onwards.  He  does  not  endeavour  to  explain  its  action,  save  to 
say  that  he  considers  it  has  a  beneficial  effect  upon  the  endo- 
metrium, and  he  points  to  his  cases  as  ample  evidence  that  the 
drug  exerts  no  deleterious  effect  upon  the  mother.  In  view  of 
Jardine's  experience,  chlorate  of  potassium  deserves  a  trial, 
especially  as  the  present  treatment  of  habitual  death  of  the 
foetus  is  so  unsatisfactory. 

*  Brit.  Med  Journ.,  October  n,  1902,  p.  1137. 


CHAPTER  VII 

ABORTION.      MISCARRIAGE.      PREMATURE    LABOUR. 
DELAYED  LABOUR. 

Abortion — Threatened  Abortion — Cervical  Abortion — Incomplete  Abortion- 
Complete  Abortion  —  Missed  Abortion.  Miscarriage  —  yEtiology  - 
Symptoms  —  Treatment.  Premature  Labour — Causes  —  Symptoms - 
Treatment.     Delayed  Labour— Symptoms — Diagnosis — Treatment. 


ABORTION. 

By  the  term  '  abortion  '  is  meant  the  expulsion  of  the  ovum  from 
the  uterus  before  the  complete  formation  of  the  placenta — that  is, 
before  the  commencement  of  the  fourth  month. 

Frequency. — The  relative  frequency  of  abortion  is  a  matter 
on  which  the  statistics  of  different  observers  differ  considerably. 
This  may  be  accounted  for  by  the  difficulty  of  obtaining  a 
reliable  history  from  women  of  their  previous  pregnancies,  and 
the  unreliable  nature  of  hospital  statistics  in  this  respect,  inas- 
much as  a  far  larger  proportion  of  women  seek  the  help  of 
hospitals  in  full -term  labour  than  in  abortion.  Priestley* 
obtained  the  pregnancy  history  of  400  private  patients  in  whom 
the  evidence  was  '  distinct  and  reliable.'  All  of  these  women 
had  reached  their  fortieth  year,  and  hence  the  history  included 
for  most  of  them  the  whole  of  the  child-bearing  period  of  life. 
These  400  women  had  been  pregnant,  collectively,  2,325  times,  and 
there  had  been  542  abortions.  The  proportion  of  abortions  to 
children  was  therefore,  about  1  to  3-2,  while  the  proportion  of 
abortions  to  pregnancies  was  about  1  to  4-2.  Of  the  400  women, 
152  had  never  aborted,  and  52  had  never  born  a  living  child. 
The  average  number  of  abortions  for  each  woman  was  thus  1*35, 
of  living  children  4*46,  and  of  pregnancies  5-8i.  These  figures 
contrast  strikingly  with  the  figures  obtained  from  the  statistics 
of  the  Rotunda  Hospital.  In  that  institution,  amongst  20,000 
patients  there  were  707  abortions,  a  proportion  of  1  to  28-28. 
This  figure  is,  as  is  only  to  be  expected  for  the  reason  given, 
very  much  below  the  normal  proportion. 

*  '  The  Pathology  of  Intra-uterine  Death,'  p.  8. 
621 


622  THE  PATHOLOGY  OF  PREGNANCY 

/Etiology. — The  causes  of  abortion  may  be  divided  into  two 
groups  : — 

(i)  Causes  which  affect   the  attachment    of  the   ovum 

to  the  uterus. 
(2)  Causes  which  bring  about  the  death  of  the  embryo. 

Causes  which  affect  the  Attachment  of  the  Ovum  to  the  Uterus. 
— Four  important  causal  factors  of  abortion  are  included  in 
this  group  : — Diseases  of  the  decidua,  or  foetal  membranes ;  inter- 
ference with  the  development  of  the  uterus  ;  direct  contraction- 
producing  agents,  or  oxytocics  ;  and  traumata. 

Diseases  of  the  decidua,  or  foetal  membranes,  are  perhaps  the 
commonest  causes  of  abortion.  In  some  cases,  as  has  been 
already  seen,  they  may  bring  about  the  death  of  the  embryo, 
and  consequently  fall  into  the  second  group ;  but  in  the  greater 
number  of  cases  they  cause  abortion  by  interfering  with  the 
normal  relations  of  the  decidua  and  the  ovum.  The  most 
common  pathological  conditions  met  with  are  decidual  endo- 
metritis, syphilis  of  the  ovum,  and  commencing  myxomatous 
degeneration  of  the  chorion.  Malignant  disease  of  the  endo- 
metrium may  perhaps  be  added  to  this  group.  It  is,  however, 
a  most  uncommon  cause,  as  its  presence  usually  ensures  sterility. 

Interference  with  the  development  of  the  uterus  is  also  a 
common  cause  of  abortion.  The  commonest  conditions  which 
interfere  with  development  are  mal-positions ;  mal- development 
and  tumours  of  the  uterus  ;  abdominal  and  pelvic  tumours,  other 
than  uterine,  which  press  upon  the  uterus ;  and  pelvic  adhesions. 

Direct  contraction-producing  agents,  or  oxytocics,  are  to  be 
found  in  certain  drugs,  as  savin,  ergot,  carbonic  acid  gas,  ex- 
cessive physical  exercise  or  mental  excitement,  and  excessive 
sexual  intercourse.  The  foregoing  are  extremely  rare  causes  of 
abortion.  The  drugs  mentioned  in  all  probability  only  exercise 
an  oxytocic  effect  when  given  in  poisonous  doses.  A  sufficient 
accumulation  of  carbonic  acid  gas  in  the  maternal  blood  to 
produce  contractions  probably  only  occurs  under  conditions 
which  produce  the  partial  or  complete  asphyxia  of  the  mother. 
Excessive  physical  exercise  or  mental  excitement  will  in  all 
probability  only  cause  abortion  when  occurring  in  association 
with  a  diseased  condition  of  the  endometrium  or  ovum,  when  it 
may  be  the  determining  cause.  Excessive  sexual  intercourse 
probably  only  produces  abortion  under  similar  circumstances. 

Under  the  head  of  traumata,  are  included  all  causes  which  can 
produce  a  sudden  detachment  of  part  of  or  of  the  whole  ovum. 
The  chief  of  these  are  falls ;  blows  on  the  abdomen  ;  the  passage 
of  instruments  into  the  uterus ;  sudden  increase  of  blood-pressure, 
as  may  occur  in  consequence  of  severe  mental  emotion  or  excite- 
ment ;  convulsions ;  vomiting ;  straining,  or  sudden  exertion  of 
any  kind. 

Causes  which  bring  about  the  Death  of  the  Embryo. — These 
causes  have  been  already  fully  discussed,  and  need  not  be  reca- 


THE  CAUSES  OF  ABORTION  623 

pitulated.  Once  the  embryo  is  dead,  the  ovum  acts  as  a  foreign 
body,  and  induces  uterine  contractions.  The  death  of  the  embryo 
is  perhaps  the  next  commonest  cause  of  abortion  to  decidual 
endometritis. 

If  the  foregoing  list  of  causes  of  abortion  is  studied,  the 
importance  and  truth  of  Hegar's  dictum  that  '  the  causes  of 
premature  expulsion  of  the  fcetus  are  generally  to  be  dated 
further  back  than  is  usually  done '  will  be  evident.  Almost  all 
the  immediate  causes  which  have  been  mentioned  are  secondary 
to  some  primary  pre-existing  cause,  and,  if  the  tendency  to  abortion 
is  to  be  cured,  it  is  the  primary  cause  which  must  be  ascertained 
and  removed.     The   two  commonest  causes  of  abortion  are,  as 


FH 


C 
Fig.  286. — An  Expelled  Ovum  embedded  in  Thickened  Decidua. 

F,  Foetus;    D,  portion  of  decidua  reflexa  ;    A,  amniotic  cavity;    C,    the 
lower  or  cervical  pole. 

we  have  stated,  decidual  endometritis  and  death  of  the  embryo. 
Decidual  endometritis  is  not  a  primary  condition,  but  is  due  to 
some  pre  -  existing  condition,  as  endometritis,  displacements, 
syphilis,  renal  disease,  etc.  Similarly,  the  death  of  the  fcetus 
is  also  due  to  some  pre-existing  condition — syphilis,  toxic  condi- 
tion of  the  maternal  blood,  constitutional  disease  of  the  mother, 
etc.  It  is  to  these  pre-existing  conditions  that  we  must  direct 
our  attention,  if  we  hope  to  prevent  the  occurrence  of  abortion, 
and  hence  the  extreme  importance  of  recognising  their  share 
in  the  aetiology  of  abortion. 

Varieties. — It  is  customary  to  divide  abortions  clinically  into 
several  groups.  The  most  common  classification  to  adopt  is 
that  which  divides  abortions  into  two  groups — threatened  abortion 
and  inevitable  abortion.  By  threatened  abortion  is  meant  the 
occurrence  of  uterine  haemorrhage  and  pain  sufficiently  marked 


624  THE  PATHOLOGY  OF  PREGNANCY 

to  show  that  some  interference  with  the  attachment  of  the  ovum 
to  the  uterus  has  occurred,  but  not  sufficiently  marked  to  preclude 
the  possibility  of  their  ceasing  and  the  pregnancy  continuing. 
By  inevitable  abortion,  on  the  other  hand,  is  meant  the  occur- 
rence of  symptoms  sufficiently  marked  to  show  that  there  is  no 
hope  of  the  pregnancy  continuing.  This  classification  has  no 
great  advantages.  It  is  not  any  more  scientific  than  the  one 
we  propose  to  adopt,  and,  inasmuch  as  it  is  difficult  to  at  once 
allocate  every  case  of  abortion  into  one-  or  other  group,  it  is 
not  of  any  very  great  practical  value.  An  abortion  is  never 
inevitable  until  so  large  a  part  of  the  ovum  is  detached  that 
its  continued  life  is  impossible,  and  it  is  impossible  in  many 
instances  to  say  that  this  has  taken  place.  The  classification 
which  we  shall  adopt  is  as  follows,  and  we  may  preface  it  by 
saying  that  the  meaning  attached  to  the.  term  '  threatened  abor- 
tion '  is  not  that  which  has  been  given  above : — 
(i)  Threatened  abortion. 

(2)  Cervical  abortion. 

(3)  Incomplete  abortion. 

(4)  Complete  abortion. 

(5)  Missed  abortion. 

Threatened  Abortion. 

Threatened  abortion  is  the  term  applied  to  the  onset  of  pain, 
haemorrhage,  and  a  varying  degree  of  dilatation  of  the  cervix,  in 
a  patient  during  the  first  three  months  of  pregnancy. 

Symptoms. — The  woman  believes  herself  to  be  pregnant,  and 
the  various  subjective  symptoms  of  pregnancy  are  present.  The 
earliest  symptom  of  the  threatening  to  abort  is  usually  an  attack 
of  uterine  haemorrhage,  accompanied  or  not  by  pain  due  to 
contraction  of  the  uterus.  The  character  and  amount  of  the 
haemorrhage  differs  in  different  cases.  It  may  come  on  suddenly 
and  violently,  or  it  may  appear  gradually  and  be  slight  in 
amount.  It  may  be  recurrent,  or  there  may  be  but  a  single 
attack.  Most  frequently,  it  occurs  as  recurrent  attacks,  at  each 
of  which  the  patient  may  lose  from  two  to  ten  ounces  of  blood. 
Similarly,  the  strength  of  the  uterine  contractions,  and  hence 
the  intensity  of  the  pain,  vary  greatly.  In  cases  in  which  the 
threatening  to  abort  is  slight,  there  may  be  no  pain  at  all,  and 
in  such  cases  the  threatening  to  abort  will  probably  pass  off. 
In  other  cases,  the  pain  may  be  most  severe,  and  in  them  the 
ovum  will  be  most  probably  expelled.  It  must  not,  however,  be 
considered  that  the  occurrence  of  uterine  contractions  necessarily 
means  that  the  abortion  is  '  inevitable.'  It  is  probable  that  in 
such  cases  the  ovum  will  be  expelled,  but,  on  the  other  hand, 
in  many  cases  the  contractions  pass  off  under  suitable  treatment, 
and  the  pregnancy  continues.  The  degree  of  dilatation  of  the 
cervix  depends  upon  the  strength  of  the  contractions  which  have 


THREATENED  ABORTION  625 

occurred,  and  the  length  of  time  for  which  they  have  been 
occurring.  In  all  cases  where  there  has  been  any  considerable 
degree  of  haemorrhage,  the  canal  will  be  more  patulous  than 
normal,  and  the  cervical  tissue  softer.  If,  however,  contractions 
are  superadded,  and  the  ovum  is  in  part  or  altogether  detached, 
the  internal  os  will  commence  to  dilate,  and  then,  in  turn,  the 
remainder  of  the  cervical  canal.  If  any  part  of  the  ovum  has 
passed  through  the  internal  os,  then  the  term  '  inevitable  abor- 
tion '  may  be  applied  to  the  condition,  if  so  desired. 

Diagnosis. — The  diagnosis  of  threatened  abortion  is  made  by 
the  history  of  the  patient  and  the  results  of  a  bi-manual  examina- 
tion. Two  points  have  to  be  determined:— First,  the  existence 
of  pregnancy,  and  secondly,  the  fact  that  the  haemorrhage  is 
coming  from  the  uterus.  Once  the  existence  of  pregnancy  is 
determined,  the  differential  diagnosis  lies  between  threatened  abor- 
tion, extra-uterine  pregnancy,  incomplete  abortion,  and  vesicular 
mole.  We  propose  to  postpone  the  discussion  of  the  differential 
diagnosis  until  the  chapter  on  the  haemorrhages  of  pregnancy,  as 
the  student  will  be  in  a  better  position  to  understand  the  different 
points  in  the  diagnosis  at  that  stage. 

Treatment. — If  we  divide  abortions  into  the  old  classification 
of  threatened  and  inevitable,  the  question  of  treatment  is  very 
simple,  and  the  only  difficulty  lies  in  allocating  each  case  to  one 
or  other  class.  Once  the  allocation  has  been  made,  then,  in 
threatened  abortion,  we  endeavour  to  prevent  the  abortion  from 
occurring,  in  inevitable  abortion  we  endeavour  to  hasten  its 
occurrence.  In  practice,  however,  the  difficulty  of  allocating 
each  case  to  one  or  other  class  is  very  considerable.  An  abortion 
can  only  be  regarded  as  inevitable  when  so  large  a  portion  of  the 
ovum  is  detached  that  the  further  life  of  the  latter  is  impossible. 
Clinically,  it  is  in  many  cases  impossible  to  state  that  this  has 
happened,  and  all  that  can  be  done  is  to  allocate  the  extreme 
cases  to  one  or  other  group,  and  to  leave  the  border-line  cases  to 
be  determined  by  future  events.  Thus,  if  a  patient  has  haemor- 
rhage, only  slight  pain,  and  no  dilatation  of  the  cervical  canal, 
the  abortion  is  only  threatened.  If,  on  the  other  hand,  a  portion 
of  the  ovum  actually  protrudes  through  the  internal  os,  then  the 
abortion  is  said  to  be  inevitable.  Between  these  two  classes  of 
case,  however,  are  found  a  considerable  proportion  of  abortion 
cases,  in  which  it  is  impossible  to  say  whether  the  abortion  is 
'  threatened  '  or  inevitable.  What  can,  however,  always  be  deter- 
mined regarding  these  cases  is  whether  they  require  palliative  or 
active  treatment.  In  many  cases  in  which  a  patient  has  a  profuse 
attack  of  haemorrhage,  the  pregnancy  might  continue  to  term,  if 
allowed  to  do  so,  but  the  condition  of  the  patient  is  such  that  we 
should  not  be  justified  in  allowing  her  to  run  the  risk  of  a  recur- 
rence of  the  haemorrhage.  In  such  a  case,  the  abortion  strictly 
speaking  is  not  '  inevitable,'  but,  practically,  we  must  adopt 
active  treatment  and  empty  the  uterus.      Again,   on  the  other 

40 


626  THE  PATHOLOGY  OF  PREGNANCY 

hand,  an  ovum  may  be  in  great  part  detached,  but  still  lying 
inside  the  uterus,  and  causing  no  great  haemorrhage  or  pain. 
The  abortion  is  '  inevitable,'  though  the  fact  cannot  be  clinically 
determined.  We  do  know,  however,  that  the  patient  presents  no 
symptoms  calling  for  active  treatment,  and,  hence,  we  adopt 
palliative  treatment  in  the  hope  that  the  pregnancy  may  continue, 
or  that,  if  it  is  doomed,  the  uterus  may  itself  expel  the  ovum. 
Accordingly,  as  we  regard  all  cases  of  abortion  as  threatened  in 
which  the  entire  ovum  still  remains  in  the  uterine  cavity,  we 
shall  subdivide  these  cases  into  two  classes  : — Cases  that  require 
palliative  treatment ;  cases  that  require  active  treatment. 

In  the  first  class  are  placed  all  cases  in  which  the  symptoms  of 
the  patient  are  not  urgent,  and  in  which  we  hope  to  be  able  to 
allow  the  pregnancy  to  continue,  if  it  will  do  so.  In  the  second 
class  are  placed  all  cases  in  which  the  condition  of  the  patient  is 
such,  in  consequence  of  the  amount  of  blood  she  has  lost,  that 
we  do  not  consider  it  safe  to  allow  her  to  lose  more. 

Palliative  Treatment. — The  palliative  treatment  of  threatened 
abortion  may  be  stated  in  general  terms  to  consist  of  measures 
calculated  to  check  haemorrhage  and  uterine  contractions.  The 
patient  is  kept  at  rest  in  bed,  in  the  recumbent  posture,  and  all 
sudden  movements  and  straining  are  forbidden.  Following  the 
advice  of  Atthill,*  and  also  influenced  by  our  own  experience  of  the 
use  of  the  drugs,  we  consider  it  advisable  to  administer  ergot  and 
strychnine  in  all  cases  in  which  there  is  haemorrhage,  but  in  which 
there  are  no  uterine  contractions.  The  advisability  of  the  use  of 
ergot  in  these  cases  has  been  already  discussed.  It  is  improbable 
that  the  drug  tends  to  produce  uterine  contractions  in  cases  in 
which  they  have  not  already  started,  while,  on  the  other  hand,  it 
appears  to  exercise  a  tonic  effect  on  the  uterine  muscle.  If,  how- 
ever, uterine  contractions  have  commenced,  the  administration 
of  ergot  may  increase  their  force,  and  so  may  tend  to  hasten  the 
expulsion  of  the  ovum.  The  drugs  are  usually  administered 
as  a  pill  or  tablet  containing  one-thirtieth  of  a  grain  of  strychnine, 
and  three  grains  of  extract  of  ergot,  the  pill  to  be  taken  twice 
or  three  times  in  the  day,  or  in  the  form  recommended  by  Atthill. 
Hydrastis  Canadensis  has  been  also  recommended  in  these  cases. 
Its  action  is,  however,  very  slight,  and  the  benefit  derived  from  it 
does  not  appear  to  be  great.  Tincture  of  opium  by  the  mouth, 
or  hypodermic  injections  of  morphia,  may  also  be  administered, 
with  the  double  object  of  relieving  any  pain  from  which  the 
patient  is  suffering,  and  of  ensuring  mental  and  physical  rest. 

Active  Treatment. — The  active  treatment  of  threatened  abortion 
consists  in  emptying  the  uterus,  with  the  object  of  preventing 
further  haemorrhage.  The  emptying  of  the  uterus  can  be  carried 
out  in  two  ways.  The  ovum  can  be  detached  and  removed  by 
the  finger  or  a  curette,  or  uterine  contractions  may  be  induced 

:;:  Op.  cit. 


THREATENED  ABORTION 


627 


by  plugging  the  vagina  or  the  uterine  cavity  with  iodoform  gauze, 
and  the  uterus  made  to  expel  the  ovum  itself. 

The  immediate  removal  of  the  ovum  by  expression,  by  the 
finger,  or  by  the  curette,  is  the  treatment  of  choice  in  all  cases  in 
which  it  can  be  carried  out.  Expression  of  the  ovum  is  only 
possible  when  the  ovum  is  detached,  and  the  cervical  canal 
sufficiently  dilated  to  allow  it  to  pass  through.  In  such  cases, 
expression  will  succeed,  and  will  obviate  all  intra-uterine  inter- 
ference. Expression  is  performed  bi-manually,  the  position  of 
the  hands  being   identical   with    their  position   when   making  a 


Fig.  2i 


-The  Bi-manual  Method  of  expressing  a  Detached  Ovum. 


bi-manual  examination  of  the  body  of  the  uterus.  The  patient 
is  placed  in  the  dorsal  position,  by  preference  across  the  bed,  or 
on  a  table.  Two  fingers  of  the  right  hand  are  then  passed  into 
the  vagina  and  placed  beneath  the  body  of  the  uterus,  that  is  to 
say,  in  the  anterior  fornix  if  the  uterus  is  normal  in  position,  in 
the  posterior  fornix  if  it  is  retroverted.  The  other  hand  is  then 
placed  on  the  abdominal  wall,  and  the  fingers  are  depressed  until 
they  come  down  on  the  superior  surface  of  the  uterine  body. 
Then,  by  pressure  on  the  body  with  the  fingers  of  both  hands, 
the  ovum  is  driven  out  of  the  uterus  into  the  vagina.  The  pro- 
cedure is  then  repeated,  with  the  object  of  expressing  any  clots 
that  have  been  left  behind. 

40 — 2 


628  THE  PATHOLOGY  OF  PREGNANCY 

The  removal  of  the  ovum  by  the  finger  is  carried  out  as 
follows : — The  fingers  of  the  right  hand  are  passed  into  the 
vagina,  and  the  left  hand  is  placed  as  before  upon  the  superior 
surface  of  the  uterine  body.  One  finger  of  the  right  hand-- 
usually  the  index  finger — is  then  passed  into  the  uterus,  and  the 
ovum  rapidly  detached  by  sweeping  the  finger  round  the  uterus 
between  it  and  the  uterine  wall.  As  soon  as  it  has  been 
completely  detached,  the  finger  is  removed,  and  the  ovum 
expressed,  as  has  just  been  described. 

The  only  advantages,  which,  in  our  opinion,  a  curette  possesses 
over  the  finger  for  the.  removal  of  the  ovum,  are  that  it  can  be  used 
when  there  is  a  less  degree  of  dilatation  of  the  cervix,  and  that  it 
is  easier  to  sterilise  than  is  the  finger.  On  the  other  hand,  in 
the  case  of  an  unskilled  operator,  it  is  more  dangerous  than  is  the 
finger,  as  it  is  by  no  means  difficult  to  pass  it  through  the  soft 
uterine  wall,  and  in  all  cases  the  finger  is  more  sensitive,  and 
enables  the  operator  to  form  a  better  opinion  as  to  whether  the 
uterus  has  been  completely  emptied.  Further,  if  rubber  gloves 
are  worn,  the  finger  is  as  aseptic  as  is  the  curette.  In  abortion 
cases,  a  blunt  curette  of  large  size  must  always  be  used,, as,  with 
a  sharp  curette,  it  is  an  easy  matter  to  scrape  away  the  softened 
fibres  of  the  uterine  wall.  The  curette  most  suited  for  the 
purpose  is  that  known  as  Rheinstadter's  flushing  curette.  This 
is  a  blunt  curette  of  considerable  size,  and  with  a  hollow  handle 
through  which  a  stream  of  water  can  be  made  to  flow  while  the 
curette  is  in  use.  By  this  means,  all  debris  is  washed  out  of  the 
uterus.  The  operation  of  curetting  will  be  described  in  its  proper 
place. 

Plugging  the  vagina  permits,  or  indeed  encourages,  the  accu- 
mulation of  blood  above  the  plug  in  the  uterine  cavity.  This  in 
itself  is  not  of  any  great,  importance,  so  long  as  the  uterus  is 
still  occupied  by  an  intact  ovum.  If,  however,  any  part  of  the 
ovum  has  come  away,  and  if  putrefactive  organisms  have  gained 
entrance  into  the  uterine  cavity,  then  "the  result  of  damming  up 
the  escaped  blood  is  to  increase  very  materially  the  dangers  of 
intra-uterine  decomposition.  It  is  not  always  possible  to  be  sure 
that  some  portion  of  the  ovum  has  not  come  away,  and,  conse- 
quently, plugging  the  vagina  is  not  an  ideal  treatment. 

Plugging  both  the  vaginal  and  the  uterine  cavity  with  iodoform 
gauze  was  first  recommended  by  Duhrssen,*  and  constitutes  a 
most  valuable  mode  of  treatment.  It  is  free  from  the  disadvantages 
which  are  associated  with  the  use  of  the  vaginal  plug  alone,  and, 
in  fact,  it  rather  tends  to  sterilise  the  uterine  cavity  than  to 
promote  its  infection.  Further,  it  can  be  adopted  when  there  is 
insufficient  dilatation  of  the  cervix  to  allow  the  introduction  of  the 
finger  or  curette,  it  is  easy  of  accomplishment,  it  checks  the 
haemorrhage  at  once,  and  it  causes  the  expulsion  of  the  ovum 
within  twenty-four  hours. 

*  '  A  Manual  of  Obstetrical  Practice,'  English  edition,  p.  118. 


CERVICAL  ABORTION  629 

The  method  of  tamponing  the  uterus  or  vagina  will  be 
described  in  its  proper  place.  It  is  sufficient  to  say  here  that  the 
material  used  for  tamponing  must  be  impregnated  with  an  anti- 
septic, as  a  simple  aseptic  material  becomes  offensive  in  a  very 
short  time  owing  to  the  decomposition  of  the  discharge  which 
soaks  into  it.  The  plugging  is  left  in  situ  for  twenty-four  hours, 
and  then  removed,  unless  there  is  an  indication  for  its  earlier 
removal.  Usually,  after  its  removal,  the  ovum  is  found  in  the 
upper  part  of  the  vagina,  but,  even  if  it  has  not  been  expelled 
from  the  uterus,  the  os  is  now  sufficiently  dilated  to  enable  it  to 
be  expressed  or  removed. 

The  treatment  of  the  patient  after  the  uterus  has  been  emptied 
is  identical  with  that  of  complete  abortion. 

Cervical  Abortion. 

A  cervical  abortion  is  the  term  applied  to  the  condition  which 
occurs  when  the  ovum  is  expelled  into  the  cervical  canal,  and 
becomes  incarcerated  there  as  a  result  of  the  failure  of  the 
external  os  to  dilate. 

Symptoms. — The  symptoms  of  the  case  are  at  first  those  of 
threatened  abortion.  Later,  when  the  ovum  has  been  completely 
expelled  into  the  cervical  canal,  the  uterus  contracts  above  it  and 
all  haemorrhage  ceases,  save  a  varying  amount  of  red  or  brownish 
discharge,  which  may  be  foetid  if  the  ovum  has  commenced  to 
decompose.  On  examination,  the  alteration  in  shape  of  the 
cervix  is  the  first  thing  noticed.  The  cervix  has  lost  its  usual 
conical  form,  and  become  ballooned  out  so  as  to  be  almost  as  wide 
as  it  is  long,  The  external  os  is  felt  as  a  small  orifice,  which  just 
admits  the  pulp  of  the  tip  of  the  examining  finger.  It  has  rigid 
parchment-like  edges,  and  presenting  at  it  can  be  felt  a  firm 
globular  mass. 

Diagnosis. — The  only  condition  for  which  cervical  abortion  can 
be  mistaken  is  that  in  which  a  fibrous  polypus  has  been  expelled 
from  the  cavity  into  the  cervical  canal,  and  lies  there  in  the  same 
manner  as  does  a  cervical  abortion.  The  physical  signs  of  the 
two  are,  as  is  only  to  be  expected,  identical,  and  the  diagnosis  is 
only  to  be  made  from  the  history  of  the  case.  The  treatment  in 
either  case  is  identical,  and  if  a  correct  diagnosis  cannot  be  made 
from  the  history,  it  will  be  made  as  soon  as  the  mass  in  the 
cervical  canal  has  been  removed. 

Treatment. — The  treatment  consists  in  dividing  the  tissues  of 
the  cervix  in  such  a  manner  as  to  increase  the  size  of  the  os 
externum,  then  in  expressing  the  ovum,  washing  out  the  uterus, 
and  suturing  the  incision.  The  incisions  are  made  bi-laterally,  and 
extend  upwards  for  half  to  three-quarters  of  an  inch,  or  farther  if 
necessary.  As  a  rule,  a  single  silkworm  gut  or  catgut  suture  in 
each  incision  will  suffice  to  bring  the  edges  together.  Each 
suture  is  passed  from  the  vaginal  surface  of  the  cervix,  and  does 
not  pass  through  the  mucous  membrane  lining  the  canal. 


630  THE  PATHOLOGY  OF  PREGNANCY 

Incomplete  Abortion. 

Incomplete  abortion  is  the  term  applied  to  the  condition  when 
part  of  the  ovum  has  been  expelled,  and  the  remainder  is  retained 
in  the  uterus. 

Symptoms. — The  early  symptoms  of  the  case  are  again  those  of 
threatened  abortion,  but,  in  addition,  there  may  or  may  not  be  a 
history  of  the  expulsion  of  some  part  of  the  ovum.  The  haemor- 
rhage, which  ushered  in  the  abortion,  gradually  ceases,  and  is 
replaced  by  a  brownish  discharge,  which  may  become  foetid  if  the 
portion  of  ovum  which  was  left  behind  decomposes.  Recurrent 
attacks  of  haemorrhage,  some  of  which  may  be  of  such  severity  as 
to  threaten  the  life  of  the  patient,  may  occur  at  any  time,  due  to 
the  separation  of  additional  portions  of  the  ovum.  If  the  intra- 
uterine decomposition  is  allowed  to  continue,  the  patient  will 
suffer  from  the  effects  of  the  absorption  of  ptomaines,  and  present 
all  the  symptoms  of  sapraemic  intoxication.  Also,  the  intra- 
ulerine  infection  may  extend  to  the  tubes,  and  thence  to  the 
peritoneal  cavity,  or  to  the  peri-uterine  connective  tissue,  giving 
rise  to  pelvic  peritonitis  or  parametritis. 

Diagnosis. — In  making  the  diagnosis  of  an  incomplete  abortion, 
two  points  have  to  be  determined : — First,  the  existence  of  an 
intra-uterine  pregnancy ;  and,  secondly,  the  fact  that  a  part  of 
the  ovum  has  been  expelled.  A  ruptured  tubal  pregnancy  and 
an  incomplete  abortion  are  particularly  liable  to  be  mistaken  for 
one  another.  The  differential  diagnosis  will  be  discussed  under 
the  head  of  tubal  pregnancy. 

Treatment. — The  treatment  of  an  incomplete  abortion  may  be 
summed  up  in  a  few  words.  The  uterus  must  be  emptied  at 
once,  and  the  incomplete  abortion  turned  into  a  complete  one. 
The  method  to  be  adopted  of  emptying  the  uterus  depends  upon 
the  period  which  has  elapsed  since  the  coming  away  of  the 
expelled  portion  of  the  ovum,  and  also  upon  the  condition  of 
affairs  present.  If  the  case  is  seen  shortly  after  the  first  portion 
of  ovum  was  expelled,  the  treatment  is  identical  with  the  active 
treatment  of  a  threatened  abortion.  The  remains  of  the  ovum 
are,  if  possible,  expressed,  and  if  that  is  not  possible,  they  are 
removed  with  the  finger  or  curette  according  to  the  size  of  the 
cervical  canal.  If  the  latter  is  insufficiently  dilated  to  permit  of 
this,  the  uterine  cavity  and  vagina  should  be  plugged  with  iodo- 
form gauze.  In  no  case  should  the  vagina  alone  be  plugged  in  a 
case  of  incomplete  abortion,  owing  to  the  danger  of  decomposition 
occurring  in  the  uterine  cavity  above  the  plug.  If  the  case  is  not 
seen  for  some  days  after  the  expulsion  of  the  first  portion  of  ovum, 
it  may  be  necessary  to  dilate  the  cervical  canal  with  Hegar's 
dilators  or  laminaria  tents.  As  soon  as  the  necessary  degree  of 
dilatation  is  obtained,  the  retained  fragments  are  removed  with 
the  finger  or  curette.  In  all  such  cases,  a  blunt  curette  is  used. 
If,  however,  a  fortnight  or  more  has  elapsed  since  the  expulsion 


COMPLETE  ABORTION  631 

of  the  ovum,  a  sharp  curette  may  be  used,  as  by  this  time  the 
uterine  wall  has  returned  somewhat  to  its  former  consistency, 
and,  moreover,  it  may  be  impossible  at  this  stage  to  remove 
retained  fragments  by  means  of  a  blunt  curette,  so  closely  have 
they  become  incorporated  with  the  uterine  wall. 

It  should  scarcely  be  necessary  at  the  present  day  to  condemn 
the  expectant  treatment  of  incomplete  abortion  ;  but  as  some 
customs  die  hard,  it  is  perhaps  safer  to  do  so.  The  expectant 
treatment  of  incomplete  abortion  was,  in  the  past,  the  usual  treat- 
ment adopted  in  these  cases,  and  was  even  recommended  by  so 
great  an  authority  as  Winckel.  It  consisted  in  waiting  in  all  cases 
of  incomplete  abortion  until  one  of  three  things  happened  : — 

(1)  The  remainder  of  the  ovum  came  away.  This  was  the 
termination  hoped  for,  and  when  it  occurred  the  advocates  of  the 
treatment  pointed  out  how  successfully  they  had  avoided  any 
intra-uterine  interference. 

(2)  The  ovum  decomposed. 

(3)  The  patient  lost  as  much  blood  from  repeated  haemorrhages 
as  was  considered  safe. 

If  the  second  or  third  termination  occurred,  the  uterus  was 
then  emptied  ;  but  unless  they  occurred,  the  condition  was  allowed 
to  persist.  The  natural  result  of  such  a  line  of  treatment  is  that 
in  a  certain  proportion  of  cases  the  remainder  of  the  ovum  comes 
away  spontaneously,  and  the  patient  gets  well.  In  other  cases, 
however,  intra-uterine  decomposition  occurs,  and  the  infection 
may  extend  to  the  tubes,  the  pelvic  peritoneum,  or  the  connective 
tissue,  and  the  patient  become  a  chronic  invalid.  In  still  other 
cases,  the  occurrence  of  sapraemic  intoxication,  in  a  patient 
weakened  by  repeated  haemorrhages,  has  proved  fatal.  This  line 
of  treatment  must  be  absolutely  condemned.  The  proportion  of 
cases  in  which  subsequent  interference  is  not  required  is  small, 
and  in  the  cases  in  which  interference  is  necessary,  it  is  more 
difficult  to  carry  out,  the  longer  it  is  postponed,  owing  to  the 
closure  of  the  cervix.  The  additional  risk,  from  sapraemia  and 
recurrent  haemorrhages,  to  which  the  patient  is  subjected  by 
waiting  is  considerable. 

Complete  Abortion. 

Complete  abortion  is  the  term  applied  to  the  expulsion  of  the 
entire  ovum. 

Symptoms. — The  initial  symptoms  are  those  of  threatened  abor- 
tion. These  may  persist  for  a  varying  number  of  hours,  and 
then  the  ovum  is  expelled. 

Diagnosis. — The  diagnosis  of  complete  abortion  is  made  when 
the  expelled  ovum  is  found  to  be  complete.  If,  however,  the 
expelled  matter  has  been  thrown  away  before  the  medical  man 
has  had  an  opportunity  of  examining  it,  it  is  often  difficult  to  be 
sure  that  the  uterus  is  empty.  The  diagnosis  of  such  cases  will 
be  subsequently  discussed. 


632  THE  PATHOLOGY  OF  PREGNANCY 

Treatment. — The  treatment  to  be  adopted  after  complete  abortion 
is  almost  identical  with  the  treatment  adopted  during  the  puerpe- 
rium.  The  patient  is  kept  at  rest  in  bed  for  at  least  five  days,  or 
until  the  discharge  has  completely  ceased.  If  possible,  she  should 
remain  in  bed  for  eight  days.  If  the  discharge  continues  longer 
than  is  right,  or  is  unduly  profuse,  ergot  may  be  administered  in 
drachm  doses  of  the  liquid  extract  twice  a  day,  or  as  a  pill  in 
combination  with  strychnine.  In  all  cases  of  abortion,  the 
patient  should  be  directed  to  visit  her  medical  adviser  in  from 
three  to  six  weeks  after  the  occurrence  of  the  abortion,  and  a 
bi-manual  examination  should  then  be  made  to  determine  the 
presence  or  absence  of  any  local  conditions  which  may  have  given 
rise  to  the  abortion,  such  as  uterine  displacements.  If  such 
conditions  are  found,  they  must  be  remedied. 

Missed  Abortion. 

Missed  abortion  is  the  term  applied  to  the  retention  of  the 
ovum  in  the  uterus  after  the  death  of  the  embryo. 

Symptoms. — The  symptoms  of  missed  abortion  are  practically 
identical  with  those  of  incomplete  abortion,  save  that  there  may 
not  be  any  haemorrhage.  There  is  a  brownish  discharge  from 
the  vagina,  and  this  will  become  fcetid  if  decomposition  of  the 
ovum  occurs.  The  uterus  diminishes  in  size,  and  the  various 
subjective  and  objective  symptoms  of  pregnancy  pass  off.  The 
patient  complains  of  various  subjective  sensations  which  are  due 
to  the  absorption  of  ptomaines  from  the  dead  ovum,  and  which 
have  been  already  described. 

Diagnosis. — The  diagnosis  is  made  from  the  history  of.  the 
patient  and  the  results  of  a  bi-manual  examination.  If  the  nature 
of  the  case  is  not  at  first  clear,  it  may  be  necessary  to  wait  for  a 
little,  and  then  to  repeat  the  examination.  The  alterations  in  the 
uterus,  if  the  ovum  is  dead,  can  then  be  usually  determined. 
The  occurrence  of  a  well-marked  brown  discharge  coming  from 
the  uterus  is  almost  positive  proof  of  the  death  of  the  ovum. 

Treatment. — The  treatment  in  these  cases  consists  in  dilating 
the  cervical  canal  and  removing  the  ovum,  either  with  the  finger 
or  the  curette.  The  usual  method  of  inducing  abortion — i.e., 
puncturing  the  membranes — is  not  sufficient  in  cases  such  as  these 
where  the  death  of  the  ovum  has  failed  to  provoke  uterine  con- 
tractions. Dilatation  of  the  cervix  may  sometimes  be  carried  out 
by  means  of  Hegar's  dilators,  but  in  most  cases  it  will  be 
necessary  to  first  insert  laminaria  tents  in  'order  to  obtain  the 
required  degree  of  dilatation.  If  the  means  of  dilatation  are  not 
at  hand,  the  uterine  cavity  may  be  plugged  with  iodoform  gauze. 
By  this  means,  uterine  contractions  will  probably  be  induced,  and 
at  any  rate  some  degree  of  dilatation  of  the  cervix  will  be 
obtained.     The  gauze  is  left  in  for  twenty-four  hours. 


MISCARRIAGE 


633 


MISCARRIAGE 

Miscarriage,  or  partus  imniaturus,  is  the  term  applied  to  the 
expulsion  of  the  ovum  between  the  time  at  which  the  placenta  is 
formed  and  the  time  at  which  the  foetus  becomes  viable,  that  is  to 
say,  between  the  beginning  of  the  fourth  and  the  end  of  the 
seventh  month. 

Aitiology. — The  causes  of  miscarriage  are  identical  with  those 
of  abortion,  with  the  addition  of  placental  disease  and  detachment. 

Symptoms. — Miscarriage  differs  from  abortion  in  that,  while  as  a 
rule  in  abortion  the  ovum  is  expelled  entire  in  a  single  stage,  in 
miscarriage  the  process  of  expulsion  is  identical  with  that  of  full- 
term  labour,  and  the  ovum  is  expelled  in  two  stages,  the  foetus 
being  driven  out  first  and  then  the  after-birth  and  membranes. 
Exceptions  to  this  rule  are  not  uncommon,  and  it  occasionally 
happens  that  the  ovum  is  expelled  intact.  In  a  series  of  389  cases 
collected  at  the  Clinic  Baudelocque,  in  which  the  ovum  was 
expelled  during  the  fourth,  fifth,  and  sixth  months,  in  23  instances 
it  was  expelled  entire. * 

The  three  chief  points  of  difference  between  miscarriage  and 
full-term  labour  are,  first,  that  as  the  foetus  is  so  small  there  is 
little  or  no  mechanism  of  labour  in  the  ordinary  sense  of  the 
word ;  secondly,  that,  since  for  the  same  reason  there  is  no 
accommodation  between  the  uterus  and  the  foetus,  abnormal 
presentations  are  relatively  more  common  than  at  full  term  ; 
and,  thirdly,  that  retention  of  the  placenta  is  a  more  common 
occurrence. 

The  increased  proportion  of  abnormal  presentations  is  well 
shown  by  the  statistics  published  by  Brion.  t  In  the  following 
table  his  statistics  are  compared  with  the  usual  proportion  of  the 
same  presentations  at  full-term,  and  with  the  proportion  as 
found  when  all  cases  of  labour  are  grouped  together  : — 


Age  of  Pregnancy. 

Percentage  of  Presentations. 

Cephalic.              Podalic. 

Shoulder. 

4  to  5  months^     - 

5  to  6  months  %     - 

6  to  7  months^     - 
Full-term  §   - 

All  cases  ||     - 

40-00                  47'27 
46'go                  46-90 
5610                  4057 
97-89                     i'6i 
96-33                     3'n 

1272 
6'ig 
3-68 
050 
0-56 

The  cause  of  placental  retention  is  usually  to  be  found  in  the 
non-separation  of  the  placenta  from  the  uterus,  owing  to  the 
presence  of  more  dense  adhesions  than  usual,  or  to  the  fact  that 
the  small  size  of  the  placenta   renders   its  detachment   by  the 

Brion,  '  Etude  Critique  sur  530  cas  d'Avortement,'  These  de  Paris,  1892. 


f  Op.  cit. 


Brion. 


§  Ribemont-Dessaignes. 


Schroeder 


634  THE  PATHOLOGY  OF  PREGNANCY 

uterine  contractions  more  difficult.  Retention  of  the  placenta  in 
these  cases  may,  however,  be  sometimes  due  to  its  incarceration, 
owing  to  the  closure  of  the  uterine  orifice.  In  cases  of  immature 
birth,  the  cervical  tissues  are  apparently  more  irritable  and  con- 
tract again  more  rapidly  than  at  full  term.  One  result  of  this 
may  be  retention  of  the  placenta,  and  another  result  is  interfer- 
ence with  the  expulsion  of  the  foetus.  The  latter  difficulty  is 
particularly  prone  to  occur  in  cases  in  which  the  foetus  presents 
by  the  breech.  In  such  cases,  expulsion  proceeds  satisfactorily 
until  all  but  the  head  has  left  the  uterus.  The  cervix  may  then 
contract  down  upon  the  neck,  and  prevent  the  descent  of  the 
head. 

Treatment. — In  view  of  the  points  of  difference  which  have 
been  mentioned  above,  there  are  accompanying  slight  differences 
in  the  treatment  of  a  miscarriage  as  compared  with  that  of  a 
full-term  labour ;  in  all  main  points,  however,  the  treatment  of 
the  two  is  identical.  It  is  never  necessary  to  correct  a  mal- 
presentation  save  in  the  case  of  a  shoulder  presentation  during 
the  sixth  and  seventh  month.  If  the  pelvic  pole  of  the  foetus 
presents,  the  arms  should  be  encouraged  to  slip  upwards  beside 
the  head  and  should  not  be  brought  down,  as  when  the  arms  are 
alongside  the  head  the  cervix  is  prevented  from  contracting  round 
the  neck,  and  so  delaying  the  birth  of  the  head.  If  the  placenta 
is  not  expelled  within  half  an  hour  of  the  birth  of  the  foetus,  and 
cannot  be  expressed,  there  is  little  object  in  waiting  any  longer, 
and  it  must  be  removed  manually.  This  is  frequently  a  trouble- 
some process,  in  consequence  of  the  cervical  canal  having  partially 
closed  so  as  to  prevent  the  introduction  of  more  than  one  or  at 
most  two  fingers  into  the  uterus. 

If  the  cervix  contracts  round  the  neck,  traction  on  the  body 
may  succeed  in  drawing  the  head  through.  The  force  of  the 
traction  must  entirely  depend  upon  the  condition  and  size  of  the 
foetus,  as  in  the  case  of  a  dead  foetus  too  vigorous  traction  will 
readily  result  in  pulling  the  body  away  from  the  head.  If  such 
an  accident  occurs,  the  head  may  be  expressed,  or,  if  small, 
may  be  caught  and  pulled  through  the  cervical  canal  with  a  pair 
of  ovum  forceps,  or  similar  contrivance.  If  it  is  large,  the  finger 
may  be  passed  into  the  mouth  and  the  head  hooked  down.  Failing 
this,  it  may  be  necessary  to  seize  it  with  a  cranioclast,  and  thus 
extract  it,  but  the  necessity  for  such  a  procedure  is  very  rare. 

The  after-treatment  of  a  miscarriage  is  identical  with  that  of  a 
full-term  labour.  As  in  the  case  of  abortion,  the  patient  should 
be  examined  in  from  four  to  six  weeks  after  the  expulsion  of  the 
ovum  in  order  to  determine,  if  possible,  the  cause  of  the  occurrence. 


PREMATURE  LABOUR  AND  DELAYED  LABOUR  635 


PREMATURE  LABOUR 

Premature  labour,  or  partus  prematums,  is  the  term  applied  to 
the  expulsion  of  the  ovum  after  the  fcetus  has  become  viable,  but 
before  full  term,  i.e.,  after  the  end  of  the  seventh  month,  and 
before  the  end  of  the  tenth. 

Causes. — Premature  labour  may  be  caused  by  most  of  the  con- 
ditions or  diseases  which  give  rise  to  abortion.  The  most  im- 
portant of  these  are  the  intra-uterine  death  of  the  fcetus,  syphilis, 
Bright's  disease,  and  traumatisms.  In  addition,  there  are  other 
causes  which  have  to  be  taken  into  account.  The  chief  of  these 
are  detachment  of  the  placenta,  usually  as  a  result  of  its  insertion 
in  the  lower  uterine  segment ;  overdistension  of  the  uterus,  as  in 
hydramnios  and  multiple  pregnancy  ;  premature  rupture  of  the 
membranes  ;  and  eclampsia. 

Symptoms. — The  symptoms  of  premature  labour  differ  but  little 
from  those  of  full-term  labour.  The  stage  of  dilatation  of  the 
cervix  may  be  somewhat  prolonged,  inasmuch  as  the  cervical 
tissues  have  not  reached  that  degree  of  softness  which  they 
normally  reach  at  full  term.  On  the  other  hand,  on  account  of 
the  small  size  of  the  foetus  its  expulsion  is  more  rapid.  Mal- 
presentations  are  slightly  more  common  than  at  full  term. 

Treatment. — The  treatment  of  the  case  is  identical  with  that  of 
normal  labour.  The  infant  must  be  kept  warm  after  birth,  and 
should,  if  possible,  be  placed  in  an  incubator.  The  management 
of  a  premature  infant  will  be  subsequently  described. 


DELAYED  LABOUR 

Delayed  labour,  or  partus  serotinus,  is  the  term  applied  to  labour 
when  it  occuis  more  than  forty-one  weeks  after  conception.  This 
is  not  a  condition  to  which  it  is  necessary  to  refer  at  any  length, 
as  labour  under  these  circumstances  does  not  differ  from  labour 
at  full-term  unless  the  fcetus  continues  to  grow,  and  so  offers  an 
obstacle  to  delivery  owing  to  its  increased  size. 

Connected  with  partus  serotinus  is  another  and  very  rare  condi- 
tion, known  as  'missed  labour.'  This  term  was  first  introduced 
by  Oldham,*  and  was  applied  by  him  to  the  condition  which 
results  when  labour  does  not  occur  spontaneously.  In  such  a 
case,  the  fcetus  dies,  and  the  liquor  amnii  is  gradually  absorbed. 
Finally,  if  the  ovum  is  retained  for  sufficient  length  of  time,  one 
of  the  various  changes  which  have  already  been  described  may 
take  place  in  the  foetus — maceration,  mummification,  or,  if  putre- 
factive bacteria  gain  entrance  to  the  uterus,  putrefaction.  If  the 
fcetus  is  retained  for  a  very  long  time,  a  deposit  of  lime  salts  on 

*  Path.  Trans.,  vol.  i. 


636  THE  PATHOLOGY  OF  PREGNANCY 

the  epidermis  may  lead  to  the  formation  of  a  calcified  covering 
which  invests  the  foetus.  To  this  condition  the  term  lithopcedion 
has  been  applied.  In  other  cases  of  long  retention,  the  foetus 
becomes  completely  disorganized,  and  is  found  as  a  mass  of 
adipocere  and  bones. 

Symptoms. — The  symptoms  to  which  missed  labour  gives  rise 
are  the  result  of  the  death  of  the  foetus,  and  of  the  absorption  of 
poisonous  matter  from  the  uterus.  They  have  been  already 
referred  to,  and  need  not  be  repeated. 

Diagnosis. — -The  diagnosis  of  missed  labour  is  made  from  the 
history  of  the  case,  the  symptoms  to  which  the  death  of  the  foetus 
gives  rise,  and  the  results  of  a  careful  examination  of  the  patient. 
Missed  labour  has  to  be  distinguished  from  the  retention  of  a 
dead  full-term  foetus  in  the  sac  of  an  extra-uterine  pregnancy.  In 
either  case,  the  symptoms  and  history  are  very  much  the  same, 
but  by  a  careful  examination  it  will  be  possible  to  determine  that 
in  the  case  of  a  missed  labour  the  foetus  is  retained  in  the  uterus, 
while  in  the  case  of  an  extra-uterine  pregnancy  the  uterus  is 
empty.  It  may  be  difficult  to  map  out  the  uterus  as  a  separate 
tumour  in  a  case  of  extra-uterine  pregnancy,  but  the  passage  of 
the  sound  will  enable  us  to  ascertain  its  position  and  contents,  or, 
if  necessary,  the  cervix  may  be  dilated  with  tents  and  the  cavity 
explored  with  the  finger.  As  the  foetus  is  obviously  dead,  and 
full  term  passed,  there  is  no  contra-indication  to  either  of  these 
proceedings. 

Treatment. — The  treatment  consists  in  dilating  the  cervix  and 
removing  the  foetus.  The  cervix  may  be  dilated  at  first  with 
tents,  and  then  further  dilatation  obtained  by  the  use  of  Frommer's 
or  of  Barnes'  dilators.  In  some  cases,  the  dilatation  of  the  cervix 
may  bring  on  uterine  contractions,  and  the  foetus  be  expelled.  If 
contractions  do  not  occur,  the  foetus  is  extracted  by  traction  on 
the  leg,  podalic  version  being  first  performed  if  necessary.  If 
the  case  is  one  of  long  standing,  and  the  foetus  is  completely 
disorganised,  the  cervix  must  be  dilated  as  far  as  possible,  and 
the  remains  of  the  foetus  removed  by  the  hand  passed  into  the 
uterus. 


CHAPTER  VIII 
EXTRA-UTERINE  PREGNANCY 

Varieties — Course  of  Pregnancy — ^Etiology — Pathological  Anatomy  ;  Changes 
in  the  Tube,  in  the  Ovum,  in  the  Uterus — Interstitial  Pregnancy — Isthmial 
Pregnancy — Ampullar  Pregnancy — Tubal  Abortion — Symptoms — Diag- 
nosis— Treatment ;  before  Rupture  of  Gestation  Sac,  at  the  time  of 
Rupture,  after  Rupture. 

Extra-uterine  pregnancy  is  the  term  applied  to  the  implantation 
and  growth  of  the  fertilised  ovum  outside  the  uterus.  This  con- 
dition is  also  known  as  ectopic  gestation. 

Varieties.  —  The  primary  varieties  of  extra-uterine  pregnancy  are 
classified  according  to  the  site  on  which  the  ovum  becomes 
implanted.  In  almost  all  cases  it  is  implanted  on  the  mucous 
membrane  of  the  Fallopian  tube,  and  to  this  variety  the  term 
tubal  pregnancy  is  accordingly  applied.  The  fertilised  ovum  may 
also  be  implanted  on  the  ovary,  or  perhaps  it  would  be  more 
correct  to  say  that  the  unfertilised  ovum  may  become  impregnated 
in  the  Graafian  follicle.  To  this  variety  the  term  ovarian  preg- 
nancy is  applied,  and  though  its  occurrence  has  been  for  long 
disputed,  at  least  five  cases*  have  been  recorded  which  are 
regarded  by  most  writers  as  definitely  establishing  the  fact 
that  such  a  condition  has  occurred.  It  is  also  considered  by 
some  observers  that  the  ovum  may  be  implanted  on  the  peri- 
toneum, and  to  this  condition  the  term  abdominal  pregnancy  is 
applied.  The  possibility  of  such  a  condition  is,  however,  very 
doubtful,  and  is  altogether  denied  by  most  observers,  in  spite  of 
the  fact  that  a  case  which  appears  to  have  no  other  possible  ex- 
planation has  been  recorded  by  Galabin.f  The  difficulty  in  the 
way  of  accepting  the  possibility  of  abdominal  pregnancy  is  that  of 
accounting  for  a  process  by  which  the  ovum  can  under  any  cir- 
cumstances become  attached  to  the  peritoneum.  Webster  J  con- 
siders   that    primary   intra-peritoneal   pregnancy   is   improbable, 

*  Tussenbroeck  (A  nnales  deGyn.,  1899,  liii.  537).  Anning  and  Littlewood 
{Trans.  Obstet.  Soc.  Lond.,  1901,  xliii.).  Thompson  (American  Gynecology, 
1902,  i.  1-15).  Gottschalk  (Centralb.  f.  Gyn.,  1886,  727).  Franz  (Hegar's 
Beitrage  zur  Geb.  und  Gyn.,  1902,  vi,  70). 

t  Trans.  Obslet.  Soc.  Lond.,  1896. 

J   '  Ectopic  Pregnancy,'  p.  14. 

637 


638 


THE  PATHOLOGY  OF  PREGNANCY 


because  the  peritoneal  tissues  cannot,  as  far  as  is  known,  undergo 
the  changes  required  for  the  establishment  of  the  necessary 
relation  with  the  young  ovum.  He,  however,  considers  ovarian 
pregnancy  to  be  j  ust  as  improbable  for  a  similar  reason. 

The  possibility  of  the  occurrence  of  either  ovarian  or  abdominal 
pregnancy  is  an  interesting  point  which  will  doubtless  be  cleared 
up  in  the  future.  However,  practically,  the  question  is  not  of  any 
great  importance.  Even  if  such  pregnancies  are  possible  they  are 
excessively  rare,  and  when  they  do  occur  they  differ  in  no  way, 
so  far  as  treatment  is  concerned,  from  the  common  form  of  extra- 
uterine pregnancy,  viz.,  tubal  pregnancy.  We  may  then  consider 
that,  for  practical  purposes,  all  cases  of  extra-uterine  pregnancy 
are  tubal  in  origin. 

The  ovum  may  develop  in  one  of  three  portions  of  the  tube.  It 
may  develop  in  the  portion  which  traverses  the  uterine  wall,  and 
in  such  a  case  we  speak  of  an  interstitial  pregnancy.  It  may 
develop  in  the  ampullar  portion — an  ampullar  pregnancy.    Lastly, 


Fig.    288. — Diagram    of    Tube    and    Ovary,    showing    the    Different 
Positions  in  which  the  Ovum  can  become  implanted. 

(I)  Interstitial;   (II)  isthmial ;  (III)  ampullar;  (IV)  ovarian. 

it  may  develop  in  the  intermediate  or  isthmial  portion — an  isthmial 
pregnancy.  As  will  be  seen,  the  course  of  events  is  affected  to  a 
considerable  extent  by  the  part  of  the  tube  in  which  the  ovum 
develops. 

A  condition,  which  is  really  an  intra-uterine  pregnancy,  may  be 
included  in  the  following  chapter,  inasmuch  as  its  symptoms, 
history,  and  treatment  are  identical  with  those  of  tubal  preg- 
nancy. This  is  pregnancy  occurring  in  a  rudimentary  horn 
of  a  bi-cornuate  uterus.  Such  a  horn  is  to  all  intents  an  ab- 
normally related  Fallopian  tube,  and  when  pregnancy  occurs  in 
it,  there  is  frequently  the  greatest  difficulty  in  distinguishing 
between  it  and  a  gravid  Fallopian  tube,  even  when  the  abdomen 
has  been  opened  and  the  parts  are  visible. 

Course  of  Pregnancy. — It  will,  perhaps,  assist  the  student  in 
understanding  this  subject  if  we  commence  by  briefly  describing 
the  usual  course  of  events  which  occur  in  a  tubal  pregnancy. 
The  impregnated  ovum  lodges  in  one  of  the  three  sections  of 
the  tube,  and  grows  there.  If  it  lodges  in  the  interstitial  section, 
the  growing  tube  encroaches  on  the  uterine  cavity ;  if  in  the 
isthmus,  the    tube   separates   the   folds    of  the  broad  ligament ; 


EXTRA-UTERINE  PREGNANCY  639 

and  if  in  the  ampulla,  the  ovum  may  protrude  through  the 
abdominal  ostium  of  the  tube.  At  some  date,  usually  between 
the  sixth  and  the  twelfth  week,  the  tube  has  reached  the 
maximum  degree  of  distension  that  it  is  capable  of,  and,  in  con- 
sequence of  the  further  growth  of  the  ovum,  it  ruptures.  In  the 
case  of  an  interstitial  pregnancy,  this  rupture  may  take  place  in 
one  of  three  directions  : — Into  the  uterine  cavity,  into  the  peri- 
toneal cavity,  or  between  the  separated  layers  of  the  broad  liga- 
ment. In  an  isthmial  pregnancy,  rupture  may  take  place  in  one 
of  two  directions  : — Into  the  peritoneal  cavity,  or  between  the 
separated  layers  of  the  broad  ligament.  In  an  ampullar  preg- 
nancy, rupture  can  occur  only  into  the  peritoneal  cavity,  but 
another  termination  is  in  this  case  also  possible—  i.e.,  the  expul- 
sion of  the  ovum  through  the  dilated  ostium  of  the  tube  into 
the  peritoneal  cavity  without  any  rupture  occurring — the  so-called 
tubal  abortion.  Rupture  of  the  tube  has  two  important  conse- 
quences— the  occurrence  of  haemorrhage,  and  the  partial  or  com- 
plete detachment  of  the  ovum.  If  the  tube  ruptures  into  the 
uterine  cavity,  the  case  will  in  all  probability  be  mistaken  for  an 
abortion,  and  will  present  the  same  symptoms.  If  the  tube 
ruptures  into  the  abdominal  cavity,  or  if  the  ovum  is  expelled 
into  the  cavity,  more  or  less  profuse  intra- peritoneal  haemorrhage 
occurs.  If  the  escaped  blood  becomes  encysted  in  Douglas's 
pouch,  the  condition  is  spoken  of  as  a  retro-uterine  haematocele. 
If  the  blood  does  not  become  encysted,  the  condition  is  spoken 
of  as  diffuse  intra-peritoneal  haemorrhage.  If  the  tube  ruptures 
into  the  layers  of  the  broad  ligament,  the  haemorrhage  is  extra- 
peritoneal. If  the  escaped  blood  does  not  travel  beyond  the 
broad  ligament,  the  condition  is  termed  a  haematoma  of  the  broad 
ligament.  If,  on  the  other  hand,  it  burrows  its  way  through  the 
sub-peritoneal  connective  tissue,  a  diffuse  sub -peritoneal  haemor- 
rhage results.  Finally,  if  the  blood  becomes  encysted  either 
intra-  or  extra-peritoneally,  the  amount  lost  will  not  be  very 
great,  or,  at  any  rate,  will  not  be  sufficient  to  cause  the  death  of 
the  patient.  If,  on  the  other  hand,  the  haemorrhage  is  diffuse, 
the  life  of  the  patient  will  almost  certainly  be  lost  unless  the 
haemorrhage  is  checked. 

The  second  important  consequence  of  rupture  is  the  effect  it 
produces  on  the  position  of  the  ovum.  If  the  ovum  is  completely 
detached  when  the  tube  ruptures,  it  almost  certainly  dies ;  if,  on 
the  contrary,  a  sufficient  portion  of  it  remains  attached  to  furnish 
the  embryo  with  the  necessary  amount  of  oxygen  and  nutriment, 
the  foetus  may  live  and  the  ovum  continue  to  grow.  In  such 
cases,  the  subsequent  history  very  largely  depends  upon  the  site 
of  the  original  rupture.  In  an  interstitial  pregnancy  that  ruptures 
into  the  uterus,  it  is  conceivable  that  the  ovum  may  not  be 
detached  and  that  pregnancy  may  continue,  the  ovum  growing 
out  into  the  uterine  cavity,  and  the  case  practically  passing  into 
an  intra-uterine  pregnancy.     If  the  tube  ruptures  into  the  peri- 


640  THE  PATHOLOGY  OF  PREGNANCY 

toneal  cavity,  and  the  ovum  continues  to  live,  the  primary  tubal 
pregnancy  is  gradually  altered  into  what  is  known  as  a  secondary 
abdominal  pregnancy.  The  ovum  gradually  extends  into  the 
abdominal  cavity,  and  the  placenta  spreads  beyond  the  limits  of 
the  tube  until  it  covers  part  of  the  pelvic  or  parietal  peritoneum, 
the  peritoneal  surface  of  the  uterus,  or  of  the  intestines.  If,  on 
the  other  hand,  the  tube  ruptures  between  the  layers  of  the  broad 
ligament,  and  the  ovum  survives  that  event,  the  latter  gradually 
extends  into  the  layers  of  the  broad  ligament,  and  the  primary  tubal 
pregnancy  is  altered  in  this  case  into  a  secondary  broad  ligamentous 
pregnancy,  or  mesometric  pregnancy,  as  it  is  sometimes  termed. 

If  a  secondary  abdominal  pregnancy  results,  the  remainder  of 
the  course  of  pregnancy  may  be  comparatively  uneventful.  If,  how- 
ever, a  broad  ligamentous  pregnancy  results,  the  course  of  preg- 
nancy is  usually  interrupted  by  a  second  rupture  of  the  gestation 
sac.  In  a  broad  ligamentous  pregnancy,  the  ovum  grows  between 
the  layers  of  the  broad  ligament,  which  is  pushed  upwards  and 
outwards.  As  the  peritoneum  is  very  elastic,  it  stands  this  dis- 
tension for  some  time,  but  in  some  cases  it  finally  becomes  over- 
distended,  as  in  the  case  of  the  tube,  and  ruptures.  The  conse- 
quences of  this  largely  depend  upon  the  situation  of  the  placenta. 
If,  as  is  perhaps  most  frequently  the  case,  the  placenta  is  situated 
above  the  ovum — that  is,  towards  the  top  of  the  broad  ligament, 
it  will  probably  be  involved  in  the  rupture,  and  the  most  serious 
haemorrhage  will  result,  almost  certainly  leading  to  the  death  of  the 
patient.  If,  however,  it  is  situated  beneath  the  ovum,  rupture  of 
the  thinned- out  upper  layers  of  the  broad  ligament  can  occur 
without  involving  it,  and  consequently  without  causing  a  neces- 
sarily fatal  haemorrhage.  In  such  a  case,  the  broad  ligamentous 
pregnancy  becomes  converted  into  an  abdominal  pregnancy. 

In  cases  in  which  the  ovum  survives  the  rupture  of  the  gesta- 
tion sac,  there  are  no  further  special  symptoms  until  full  term  is 
reached.  Then,  a  form  of  false  labour  may  be  set  up,  the  uterus 
expels  a  decidual  cast  of  its  cavity,  and  the  foetus  dies.  If  the 
dead  fcetus  is  allowed  to  remain  in  the  abdominal  cavity,  putre- 
faction, or  the  formation  of  a  lithopaedion  may  result.  If  putrefac- 
tion occurs,  an  abscess  will  result  and  burst  into  some  of  the 
hollow  viscera  or  through  the  parietes.  Such  an  abscess  may 
continue  to  discharge  for  years,  if  the  patient  lives,  and  during 
that  period  fragments  of  the  foetus  will  come  away  piecemeal. 
In  cases  in  which  putrefaction  and  suppuration  have  not  occurred, 
women  have  been  known  to  carry  about  the  remains  of  a  full- 
term  fcetus  for  upwards  of  forty  years. 

This  brief  outline  of  the  course  of  tubal  pregnancy  will  enable 
the  student  to  understand  more  clearly  the  symptoms  and  physical 
signs  of  the  three  periods  into  which  we  shall  divide  tubal  preg- 
nancy, as  well  as  the  reasons  for  so  dividing  it.  These  periods 
are  : — From  the  commencement  of  pregnancy  to  the  occurrence 
of  rupture ;  at  the  time  of  rupture  ;  and  from  the  occurrence  of 


THE  CAUSES  OF  EXTRA-UTERINE  PREGNANCY  641 

rupture  to  the  removal  of  the  ovum.  It  will  be  seen  here  that  we 
have  alluded  to  but  one  period  of  rupture.  This  is,  however, 
clinically  sufficient.  Secondary  rupture  only  occurs  in  a  certain 
proportion  of  cases,  and  in  these  cases  the  symptoms  of  primary 
rupture  have  been  little  if  at  all  marked.  The  reasons  for  this 
are  obvious.  In  the  first  place,  when  the  ovum  is  expelled 
between  the  layers  of  the  broad  ligament  there  is  usually  little 
haemorrhage.  In  the  second  place,  if  there  was  sufficient  haemor- 
rhage to  cause  serious  symptoms,  the  death  of  the  ovum  would 
almost  certainly  occur,  and  consequently  there  would  be  no  ovum 
to  cause  a  secondary  rupture.  Accordingly,  although  actually  in 
these  cases  there  are  two  ruptures — one  of  the  tube,  and  the  other 
of  the  investing  broad  ligament,  clinically  our  attention  is  drawn 
to  one  or  other  alone,  for  the  reasons  given. 

Etiology. — The  question,  What  causes  an  extra-uterine  preg- 
nancy ?  is  closely  connected  with  another  equally  important 
question,  Where  is  the  normal  site  of  fertilisation  of  the  ovum  ? 
It  is  obvious  that  until  the  latter  question  is  satisfactorily  answered 
only  vague  surmises  can  be  given  as  an  answer  to  the  former. 
The  various  views  regarding  the  normal  site  of  fertilisation  may 
be  reduced  to  three  : — That  the  ovum  is  always  fertilised  in  the 
uterine  cavity  ;  that  the  ovum  is  always  fertilised  in  the  tube  ; 
and  that  it  may  be  fertilised  at  any  point  on  its  route  between  the 
ovary  and  the  uterus,  or  in  the  uterus  itself. 

The  first  of  these  views  was  advocated  strongly  by  Lawson 
Tait,*  who  considered  that '  the  uterus  alone  is  the  seat  of  normal 
conception,  and  that  the  function  of  the  ciliated  lining  of  the 
Fallopian  tube  is  to  prevent  spermatozoa  from  entering  the  tube.' 
Bland-Suttont  also  supports  this  view,  and  states  that  when 
fertilisation  '  occurs  in  the  tubes  it  is  accidental,  and  tubal  gesta- 
tion is  the  consequence.'  In  accordance  with  this  view,  Tait 
looked  for  the  cause  of  extra-uterine  pregnancy  in  any  condition 
which  destroyed  the  ciliated  epithelium.  Bland-Sutton  does  not 
apparently  commit  himself  in  the  article  quoted  to  any  definite 
statement  of  cause,  but  considers  that,  wherever  the  ovum  is 
fertilised,  it  engrafts  itself  on  the  adjacent  mucous  membrane 
whether  tubal  or  uterine.  Tait's  notion  regarding  the  action  of 
the  ciliae  had  some  support  when  it  was  believed  that  the  ciliae  of 
the  uterus  and  of  the  tubes  acted  in  opposite  directions,  the 
uterine  ciliae  moving  towards  the  fundus,  the  tubal  ciliae  from  the 
abdominal  to  the  uterine  ostium.  Under  such  circumstances,  it 
was  not  unnatural  to  believe  that  the  function  of  these  opposing 
movements  was  to  bring  the  ovum  and  spermatozoon  together  in 
the  uterine  cavity.       Hofmeier,;   however,  has    proved  that  the 

*  'Lectures  on  Ectopic  Gestation  and  Pelvic  Haematocele, '  Birmingham, 
1888,  p.  107. 

t  'Extra-Uterine  Pregnancy,'  Allbutt  and  Playfair's  'System  of  Gynae- 
cology,' p.  451. 

X  Centralb.  f,  Gyn.,  1893,  No.  33,  764-766. 

41 


642  THE  PATHOLOGY  OF  PREGNANCY 

direction  of  the  movements  of  the  ciliae  is  downwards  in  both 
uterus  and  tube,  that  is  from  the  abdominal  ostium  to  the  cervix, 
and  that,  consequently,  there  is  no  natural  mechanism  of  this 
kind  to  promote  a  union  in  the  uterus.  Moreover,  Diihrssen*  has 
found  spermatozoa  not  only  in  the  Fallopian  tubes  after  extirpa- 
tion, but  also  in  the  abdominal  ostium,  in  cases  where  there  was 
no  tubal  disease.  It  is  difficult  then  to  believe  that  the  uterus  is 
the  sole  normal  site  of  fertilisation  of  the  ovum. 

The  second  view  that  the  ovum  is  always  fertilised  in  the 
Fallopian  tube  is  strongly  held  by  Strassmann,  with  the  support 
of  Bischoff  and  His,  who  consider  that  '  fructification  takes  place 
in  the  Fallopian  tube  probably  at  the  fimbriated  end,  and 
immediately  after  the  exit  of  the  ovum  from  the  follicle.  If  this 
is  so,  every  pregnancy  begins  as  an  extra-uterine  one,  and  the  fact 
that  it  remains  extra-uterine  will  probably  be  due  to  a  retarded 
movement  of  the  fructified  ovum.'f  This  view  is  difficult  to  dis- 
prove and  impossible  to  prove.  It  is  unquestionable  that,  when 
the  normal  unfertilised  ovum  is  set  free  from  the  Graafian 
follicle,  it  traverses  the  tube,  passes  into  the  uterus,  and  is  thence 
expelled.  If  the  tube  is  the  only  normal  site  of  fertilisation,  then 
coitus,  to  result  in  impregnation,  must  take  place  before  the  ovum 
has  passed  into  the  uterine  cavity.  Consequently,  either  the 
ovum  must  take  a  considerable  time  in  passing  through  the  tube, 
or  else  fertilisation  can  only  take  place  within  a  very  short  period 
after  ovulation.  It  is,  however,  to  say  the  least  of  it,  improbable 
that  the  ovum  takes  a  long  time  to  pass  through  the  tube,  as  it 
cannot  subsist  on  its  yelk  for  more  than  a  short  time  ;  while,  if  it 
passes  through  rapidly,  the  available  time  during  which  a 
fertilising  coitus  can  take  place  must  be  equally  short.  It  would 
then  appear  that  the  third  view  which  we  have  mentioned  is  the 
most  probable,  and  that  fertilisation  can  take  place  at  any  point 
between  the  ovary  and  the  uterine  cavity,  or  in  the  latter.  In 
view  of  the  many  curious  and  unexplained  phenomena  with  which 
the  process  of  fertilisation  is  surrounded,  it  is  not  very  difficult  to 
consider  that  there  is  a  natural  attraction  between  the  ovum  and 
the  spermatozoon,  which  tends  to  bring  them  together.  If  the 
spermatozoon  meets  the  ovum  in  the  uterus,  fertilisation  occurs 
there.  If  the  spermatozoon  reaches  the  uterus  before  the  ovum, 
the  same  tendency  will  draw  it  into  the  tube  to  meet  the  ovum. 
If  the  ovum  has  not  as  yet  entered  the  tube,  the  spermatozoon 
may  reach  the  fimbriated  extremity,  or  even  pass  into  the  peritoneal 
cavity.  The  fertilised  ovum  will  then,  under  normal  circum- 
stances, continue  its  course  to  the  uterus,  where  it  becomes 
embedded. 

If,  then,  we  accept  the  view  that,  under  normal  circumstances, 
the  spermatozoa  may  find  their  way  into  the  Fallopian  tubes,  we 
have  next  to  determine,  so  far  as  possible,  the  factors  which  cause 

*  Archiv  f.  Gyndk.,  Band  liv.,  Heft  2,297. 

f  '  Beitrage  zur  Lehre  von  der  Ovulation,'  etc.,  Archiv  f.  Gyndk.,  1896. 


THE  CAUSES  OF  EXTRA-UTERINE  PREGNANCY  643 

the  fertilised  ovum  to  remain  in  the  tube  instead  of  descending 
into  the  uterus.  These  factors  are  probably  to  be  found  in 
conditions  which,  while  offering  no  obstruction  to  the  ascent  of 
the  spermatozoon,  prevent  the  descent  of  the  fertilised  ovum. 
Such  conditions  are  inflammatory  hyperplasia  or  hypertrophy  of 
the  tubal  mucous  membrane  ;  diverticula  of  the  tube  ;  ex- 
aggerated convolutions  ;  accessory  fimbriated  extremities  ; 
cicatricial  contractions  or  obstruction  by  bands  of  adhesions  or 
from  the  pressure  of  tumours  or  neighbouring  organs  ;  and  the 
presence  of  intra-tubal  tumours.  An  interesting  case  in  which 
the  last-named  condition  was  probably  the  cause  of  a  tubal 
pregnancy  is  recorded  by  Dubrssen.*  In  it,  a  small  polypus 
appeared  to  have  formed  a  very  perfect  ball- valve,  which  allowed 
bodies  to  pass  from  the  uterus  to  the  ovary,  but  prevented  them 


O 

Fig.   289. — A  Ruptured  Fallopian  Tube. 

O,  An  accessory  abdominal  ostium. 

(From  a  specimen  removed  by  operation  by  Dr.  W.  J.  Smyly. ) 

from  passing  in  an  opposite  direction.  The  pregnancy  was  found 
at  the  ovarian  side  of  this  obstruction.  In  a  case  operated  on  by 
Smyly,  a  small  accessory  fimbriated  extremity  was  present 
(v.  Fig.  289). 

Some  observers,  and  notably  Webster,  while  admitting  the  part 
played  in  the  causation  of  tubal  pregnancy  by  obstruction  to  the 
descent  of  the  fertilised  ovum,  consider  that  another  factor  is  also 
necessary.  This  factor  Webster  considers  is  to  be  found  in  some 
developmental  fault  in  the  tubal  mucous  membrane  which  permits 
it  to  respond  to  what  he  terms  '  genetic  influence,'  that  is  to  say, 
to  take  its  part  in  the  formation  of  a  decidua  as  does  the  mucous 
membrane  of  the  uterus.  If  this  power  of  response  is  wanting, 
the  ovum  may  become  retained  in  the  tube,  but  it  will  not  be  able 
to  take  root  there  and  grow.  Given,  however,  '  the  fertilisation 
of  the  ovum  high  in  the  tube,  the  obstruction  to  its  free  passage 

*   '  Ueber  Operative  Behandlung,'  Archiv  f.  Gyncik.,  Band  liv.,  Heft  2,  1897. 

41 — 2 


644 


THE  PATHOLOGY  OF  PREGNANCY 


to  the  uterus  after  this  takes  place,  along  with  the  occurrence  of 
the  necessary  decidual  reaction  in  the  mucosa  with  which  the 
ovum  comes  in  contact,  and  we  have  a  satisfactory  explanation  of 
the  pregnancy  which  develops.'*  This  view  is  very  plausible  so 
far  as  tubal  pregnancies  are  concerned.  The  occurrence  of  an 
ovarian  or  primary  abdominal  pregnancy  would,  however,  seem 
to  show  that  such  a  power  of  response  to  genetic  influence  was 
not  necessary. 

We  may  sum  up  the  views  on  the  aetiology  of  tubal  pregnancy 
which  appear  to  us  to  be  the  most  probable,  in  the  words  of 
Taylor,!   whose   conclusions   appear   to    be  probably   as  nearly 


Fig.  290. — The  Ovum  which  escaped  from  the  Ruptured  Tube  shown 

in  Fig.  289. 

Note  the  massing  of  the  villi  at  one  pole  of  the  ovum. 

correct  as  any  can  hope  to  be  in  the  present  state  of  our  know- 
ledge : — 

(1)  Normal  impregnation  of  the  ovum  is  not  limited  to  the 
uterus,  but  may  occur  anywhere  in  the  Fallopian  tube  or  imme- 
diately on  the  exit  of  the  ovum  from  the  ovary. 

(2)  Normal  attachment  and  development  of  the  ovum  is  limited 
to  the  uterus. 

(3)  Abnormal  arrest  of  the  impregnated  ovum,  whether 
mechanical  or  special,  in  its  progress  towards  the  uterus  is  the 
determining  factor  of  a  misplaced  pregnancy.  An  extra-uterine 
pregnancy  is,  therefore,  the  result  of  the  permanent  arrest  of  a 
fructified  ovum  in  its  passage  from  the  ovary  to  the  uterus. 

*  Op.  cit.,  p.  13. 

f  'Extra-Uterine  Pregnancy,'  Brit.  Gyn.  Jour.,  May,  1898,  p.  89.  We 
desire  also  to  acknowledge  our  indebtedness  to  Mr.  Taylor's  article  for  many 
references  and  for  much  information  on  the  present  subject. 


rATHOLOGICAL  ANATOMY  OF  EXTRA-UTERINE  PREGNANCY  645 

Pathological  Anatomy. — Changes  in  the  Tube. — The  changes 
which  take  place  in  the  tube  depend  to  a  considerable  extent 
upon  the  exact  site  of  implantation  of  the  ovum.  The  following 
changes,  however,  may  be  considered  as  common  to  the  different 
sites.  The  tube  increases  in  size  to  suit  the  growing  ovum.  At 
first,  its  muscular  fibres  hypertrophy,  but,  later— from  the  third 
month  on— they  are  apparently  unable  to  hypertrophy  further, 
and  as  the  ovum  grows  the  bundles  of  muscle  fibre  become  widely 
separated,  and  atrophy.  In  the  rare  instances  in  which  the  ovum 
has  been  found  at  an  advanced  stage  of  pregnancy  in  an  un- 
ruptured tube,  there  is  no  appearance  of  muscle  fibre  in  the  tube 
wall  save  in  a  few  isolated  areas.  The  bloodvessels  of  the  tube 
are  somewhat  increased  in  size,  and,  subsequently,  if  the  foetus 
continues  to  develop,  reach  very  considerable  dimensions  in  order 
to  bring  the  necessary  supply  of  blood  to  the  placenta.  In  some 
cases,  the  abdominal  ostium  is  closed  by  a  curious  mechanism. 
The  hyperaemia  of  the  parts  leads  to  a  turgescence  of  the 
peritoneum  and  muscular  coat.  This  turgescence  causes  these 
structures  to  form  an  irregular  ring  round  the  base  of  the  fimbriae, 
at  about  the  end  of  the  fourth  week.  A  little  later,  in  consequence 
of  the  increased  hyperaemia,  the  swollen  peritoneum  projects  like 
a  sleeve  beyond  the  fimbriae,  and  the  latter  are  turned  inwards 
into  the  lumen  of  the  tube.  Finally,  the  edges  of  this  sleeve 
gradually  come  into  contact  with  one  another  and  adhere,  so 
completely  closing  the  ostium.  In  such  a  case,  the  distal  end 
of  the  tube  as  seen  from  without  will  appear  as  a  blunt  rounded 
stump.  If,  however,  the  tube  is  opened,  the  fimbriae  will  all  be 
found  tucked  away  inside.  This  process  most  usually  occurs  in 
the  case  of  an  ampullar  pregnancy,  and,  when  the  ovum  is  im- 
planted in  the  inner  two-thirds  of  the  tube,  it  is  not  so  common. 
In  some  cases,  quite  the  opposite  condition  of  the  ostium  is  found, 
and  the  latter  is  represented  by  an  annular  opening,  measuring 
perhaps  nearly  an  inch  in  diameter.  This  is  usually  the  case 
when  the  ovum  is  implanted  in  the  infundibulum  of  the  tube,  and 
projects  through  the  ostium  as  it  grows,  causing  the  so-called 
tubo-ovarian  or  tubo-peritoneal  pregnancy. 

It  is  most  probable — if  not  certain — that,  in  all  cases,  a  decidua 
vera  is  formed  in  the  tube.  As  in  the  case  of  the  uterine 
decidua,  the  vera  consists  of  a  superficial  compact  layer  and  a 
deep  spongy  layer.  The  existence  of  a  decidua  reflexa  in  all 
cases  is  more  doubtful.  The  relation  between  the  size  of  the 
ovum  and  that  of  the  lumen  of  the  tube  is  altogether  different  from 
the  relation  between  the  size  of  the  ovum  and  that  of  the  uterine 
cavity  (Webster*),  and,  consequently,  the  decidua  vera  may  soon 
come  into  contact  all  round  with  the  ovum,  and  thus  render  the 
formation  of  a  distinct  reflexa  impossible.  If,  on  the  other  hand, 
the  tubal  lumen  is  large,  and  the  ovum  is  only  attached  to  one 
portion  of  its  wall,  a  more  or  less  complete  decidua  may  be 
formed. 

*  Op.  cit.,  p.  130. 


646  THE  PATHOLOGY  OF  PREGNANCY 

Changes  in  the  Ovum. — The  ovum  develops  in  the  tube  in  a 
similar  manner  to  that  in  which  it  develops  in  the  uterus  save 
that  it  is  more  liable  to  be  interfered  with  by  traumatisms.  It 
not  infrequently  happens  that  the  death  of  the  foetus  is  caused  by 
repeated  intra-tubal  haemorrhages,  or  by  haemorrhage  into  the 
sub-chorionic  chamber,  i.e.,  the  space  between  the  chorion  and  the 
amnion.  These  haemorrhages  are  gradual  and  recurrent,  and 
result  in  the  formation  of  a  laminated  clot,  which  invests  the 
entire  ovum  or  the  amniotic  sac,  as  the  case  may  be.  To  this 
condition  the  term  tubal  mole  is  applied.  Bland-Sutton,  who 
has  studied  these  moles,  considers  that  the  blood  is  usually 
limited  externally  by  the  chorion  and  internally  by  the  amnion, 
and  that  it  is  derived  from  the  circulation  of  the  embryo,  while 
any  blood  which  invests  the  ovum  externally  comes  from  the 
maternal  circulation.  The  main  proof  which  he  offers  of  the 
former  statement  is  that  the  blood-cells  found  in  the  clot  are 
nucleated.  It  must,  however,  be  difficult  to  determine  whether  a 
blood-cell  in  a  clot  is  nucleated  or  not,  and  we  find  an  insuperable 
difficulty  in  explaining  how  an  embryo  a  few  weeks  old  can 
supply  an  amount  of  blood  which  must  be  from  three  to  six 
times  its  own  volume.  It  would  certainly  seem  that,  although 
the  embryo  may  contribute  a  few  nucleated  blood  corpuscles,  the 
large  proportion  of  the  blood  must  come  from  the  maternal 
circulation. 

The  consequences  of  the  formation  of  a  moie  are,  as  in  the 
case  of  a  uterine  pregnancy,  recurrent  haemorrhages.  If  the  ostia 
of  the  tube  are  occluded,  this  results  in  the  increase  in  size  of 
the  mole,  and  the  ultimate  rupture  of  the  tube.  If,  on  the 
other  hand,  the  abdominal  ostium  is  patent,  the  blood  is  expelled 
into  the  abdominal  cavity,  where  it  forms  a  mass  surrounding  and 
adherent  to  the  fimbriated  extremity  of  the  tube.  In  some  cases, 
the  blood  coagulates  in  the  tube,  and  is  then  expelled  through 
the  ostium  by  the  pressure  of  further  haemorrhage  as  a  long 
sausage -shaped  mass,  which  has  been  found  coiled  up  in 
Douglas's  pouch  (Noble).  The  history  of  tubal  rupture,  the  result 
of  mole  formation,  is  identical  with  rupture  the  result  of  a  living 
ovum,  save  that  in  the  former  case  there  is  no  living  ovum  to 
continue  to  grow.  When  a  mole  forms  in  the  case  of  an  ovum 
situated  in  the  infundibulum  of  the  tube,  it  is  often  expelled 
partially  or  completely  into  the  peritoneal  cavity.  To  this  process, 
the  term  tubal  abortion  has  been  given. 

The  changes  which  take  place  in  the  ovum  in  which  the  foetus 
dies,  but  no  tubal  mole  is  formed,  have  been  already  briefly 
alluded  to.  Probably,  up  to  the  end  of  the  third  month,  the 
most  common  termination  is  its  complete,  or  almost  complete, 
absorption.  After  this  period,  the  foetus  and  placenta  have 
reached  too  great  a  size  to  be  completely  absorbed,  and  one  or 
other  of  the  changes  which  have  been  already  mentioned  occur. 
If  the  ovum  is  infected  by  bacteria  from  the  intestines,  it  decom- 


PATHOLOGICAL  ANATOMY  OF  EXTRA-UTERINE  PREGNANCY  647 

poses  and  an  abscess  results.  If  this  abscess  is  limited  to 
Douglas's  pouch,  it  will  follow  the  same  course  as  does  a  sup- 
purating hematocele.  If,  however,  pregnancy  was  further 
advanced,  the  abscess  may  form  anywhere  in  the  abdominal 
cavity  according  to  the  position  in  which  the  fcetus  lay.  Such 
abscesses  may  reach  a  considerable  size,  and,  finally,  burst  into 
one  of  the  hollow  viscera  or  vagina,  or  through  the  abdominal 
wall.  They  may  then  continue  to  discharge  for  years,  until  either 
the  patient  succumbs  to  the  long-continued  suppuration,  or  the 
remains  of  the  ovum  are  completely  expelled.  In  248  cases 
collected  by  Webster,  the  abscess  burst  into  the  intestinal  canal 
in  55  per  cent,  of  cases  ;  through  the  abdominal  wall  in  23  per 
cent.  ;  into  the  vagina  in  12  per  cent.  ;  and  into  the  bladder  in  10 
per  cent. 

The  other  changes  which  may  take  place  in  the  foetus  are 
mummification,  conversion  into  adipocere,  and  calcification. 
The  last-named  change  may  affect  the  membranes  alone,  or  may 
also  affect  the  fcetus,  a  thick,  compact,  but  fragile  crust  forming 
over  the  latter,  '  as  if  the  vernix  caseosa  had  been  altered ' 
(Webster). 

The  changes,  which  take  place  in  the  relations  of  the  placenta 
and  membranes  to  the  surrounding  parts  after  the  rupture  of  the 
tube  or  the  secondary  gestation  sac,  will  be  referred  to  a  little  later. 

It  was  formerly  considered  by  many  observers  that  the 
placenta  continued  to  grow  after  the  death  of  the  foetus.  This 
opinion  was  apparently  based  on  the  fact  that  in  many  cases  the 
placenta  increased  in  size.  This  increase  has,  however,  been 
found  to  be  due,  not  to  any  further  growth  in  its  essential 
elements,  but  to  extravasations  of  maternal  blood  into  its  sub- 
stance. These  haemorrhages  may  be  slight,  or  they  may  be  so 
considerable  as  to  alter  the  placenta  from  a  thin  discoid  mass  to  a 
comparatively  thick  or  almost  oval  body.  Subsequently,  these 
extravasations  are  converted  into  masses  of  fibrin,  the  villi  de- 
generate, and  finally  the  mass  becomes  organised  into  fibrous 
tissue  of  a  low  type  into  which  the  maternal  vessels  extend 
(Webster). 

Changes  in  the  Uterus. — The  uterus  invariably  increases  in 
size  pari  passu  with  the  growth  of  the  ovum  in  the  tube.  It  never, 
however,  attains  the  same  size  as  would  be  the  case  if  the  preg- 
nancy was  intra-uterine.  Its  shape  remains  that  of  the  non- 
impregnated  uterus,  and  does  not  assume  the  globular  outline 
characteristic  of  pregnancy  during  the  first  four  months.  The 
uterus  in  the  case  of  an  extra-uterine  pregnancy  is  usually,  during 
the  first  four  months,  from  a  third  to  a  fourth  smaller  than  a 
pregnant  uterus  of  the  same  date.  After  that,  it  may  still  increase 
in  size,  but  the  increase  is  less  rapid.  At  term,  it  has  been  found 
to  measure  from  four  to  seven  and  a  half  inches  in  length.  Many 
of  the  other  changes  characteristic  of  pregnancy  may  occur  to 
a  slight  extent,  but  are  not  so  marked  as  in  uterine  pregnancy. 


648  THE  PATHOLOGY  OF  PREGNANCY 

The  body  is  softer  than  in  the  non-impregnated  state,  and  so  is 
the  cervix.  The  cervical  canal  may  be  slightly  patulous,  and 
contain  a  plug  of  mucus.  Apparent  shortening  of  the  cervix 
may  be  noticeable.  The  position  of  the  uterus  is  altered  accord- 
ing to  the  position  and  size  of  the  extra-uterine  pregnancy. 

Next  to  the  increase  in  size  of  the  organ,  the  most  important 
change  is  the  formation  of  a  decidua.  This  decidua  resembles 
closely  the  decidua  vera  in  a  case  of  uterine  pregnancy,  lines  the 
entire  cavity,  and  varies  in  thickness  from  6  to  10  millimetres. 
When  expelled  in  one  piece  it  is  triangular  in  shape,  the  base  of 
the  triangle  corresponding  to  the  fundus,  and  the  angles  at  the 
base  to  the  openings  of  the  Fallopian  tubes.  The  uterine  aspect 
is  shaggy  and  rough,  the  free  aspect  smooth.  Microscopically,  the 
connective-tissue  cells  of  the  endometrium  have  been  converted 
into  decidual  cells,  the  superficial  portions  of  the  glands  have  been 
compressed  and  partially  obliterated,  while  the  capillaries  are 
dilated.  Some  observers  consider  that  the  nearer  the  extra- 
uterine pregnancy  is  situated  to  the  uterus,  the  more  marked  is 
the  decidual  formation.  The  decidua  may  be  expelled  from  the 
uterus  at  any  time  during  the  progress  of  an  extra-uterine 
pregnancy.  Expulsion,  however,  is  particularly  likely  to  occur 
at  the  time  of  rupture  of  the  tube,  or  at  full  term  if  the  ovum  lives 
to  that  time.  The  decidua  may  be  expelled  in  a  single  mass,  and 
form  a  cast  of  the  interior  of  the  uterus,  as  has  been  described,  or 
it  may  be  expelled  piecemeal  at  different  times.  If  it  is  not 
expelled  in  either  of  these  ways,  it  may  undergo  atrophy,  de- 
generation, and  absorption,  as  in  the  case  of  the  decidua  of  an 
intra-uterine  pregnancy. 

At  full  term,  a  form  of  spurious  labour  occurs.  The  uterus 
contracts,  the  cervical  canal  dilates  to  a  variable  extent,  and  the 
decidua  is  expelled,  if  its  expulsion  has  not  already  occurred.  There 
is  an  accompanying  haemorrhage,  and  the  contractions  may  give 
rise  to  considerable  pain.  It  is  impossible  at  present  to  state  what 
may  be  the  cause  of  these  contractions.  The  foetus  usually  dies 
at  or  about  the  same  time,  but  its  death  does  not  necessarily 
precede  the  occurrence  of  contractions.  It  has  been  suggested 
that  the  changes  in  the  decidua  have  become  so  marked  that  the 
latter  is  to  all  intents  and  purposes  a  foreign  body,  and  so  stimulates 
the  uterus  to  contract  (Hennig).  In  some  cases,  however,  the 
decidua  has  been  already  expelled.  It  is  probable  that  in  all  cases 
of  pregnancy — intra-  or  extra-uterine — the  occurrence  of  labour, 
true  or  false,  is  governed  by  a  law  which  allows  to  pregnancy  a 
certain  period,  or  cycle.  There  is  a  cardiac  cycle,  a  respiratory 
cycle,  a  menstrual  cycle,  and  probably  a  gestation  cycle,  the 
periodicities  of  which  are  governed  by  laws  of  which  nothing  is 
known.  In  the  case  of  the  gestation  cycle,  these  laws  probably 
act  whether  the  pregnancy  is  in  the  uterus  or  outside  it,  and  the 
objective  sign  that  they  have  commenced  to  act  is  furnished 
by  the  occurrence  of  uterine  contractions. 


INTERSTITIAL  AND  ISTHMIAL  PREGNANCY  649 

A  few  words  must  now  be  said  on  the  subject  of  each  form  of 
tubal  pregnancy. 

Interstitial  Pregnancy. 

An  interstitial  or  tubo-uterine  pregnancy  is  the  rarest  form  of 
extra-uterine  pregnancy.  In  this  condition,  the  gestation  sac  is 
embedded  in  the  uterine  wall,  and  causes  marked  asymmetry  of 
that  organ.  As  the  ovum  grows,  the  wall  of  the  sac  becomes 
thinned  out,  especially  in  its  upper  portion,  and  the  muscle 
fibres  in  great  part  disappear,  as  is  shown  by  a  case  recorded 
by  Webster,*  in  which  the  thinnest  part  of  the  wall  was  only  the 
one-thirty-second  part  of  an  inch  in  thickness,  and  contained  only 
a  trace  of  muscle  fibre.  Rupture  usually  occurs  somewhat  later 
than  is  the  rule  in  ampullar  or  isthmial  pregnancies,  in  conse- 
quence of  the  thicker  walls  of  the  sac,  but  in  almost  every  case 
it  occurs  before  the  fifth  month.  Cases  have,  however,  been 
recorded  in  which  the  pregnancy  went  on  to  full  term  without 
rupture.  Rupture  may  occur  into  the  peritoneal  cavity,  into 
the  uterine  cavity,  or  into  both  cavities.  The  first  of  these  is 
the  most  common.  Rupture  into  the  peritoneal  cavity  in  these 
cases  is  a  most  serious  accident,  and  is  even  worse  than  in  the 
other  tubal  forms,  due  in  part  to  the  later  period  of  pregnancy  at 
which  the  rupture  usually  occurs,  and  in  part  to  the  involvement 
of  the  larger  vessels  of  the  uterine  wall.  In  26  cases  collected  by 
Hecker,f  the  death  of  the  mother  occurred  in  every  one.  Rupture 
usually  occurs  at  the  upper  portion  of  the  sac,  which,  as  has  been 
mentioned,  is  the  thinnest  part.  Rupture  into  the  uterine  cavity 
may  not  be  so  serious.  Its  occurrence  tends  to  prove  that  the 
outer  wall  of  the  sac  is  comparatively  thick,  and,  consequently,  ii 
the  ovum  is  entirely  expelled  into  the  uterine  cavity,  contraction 
of  the  muscle  fibres  remaining  in  the  wall  may  be  sufficient  to 
check  the  haemorrhage.  It  is  possible  that  in  rare  cases  the  uterine 
end  of  the  tube  may  dilate,  and  the  ovum  be  expelled  through 
it.  Double  rupture  of  the  sac  into  both  the  peritoneal  and  uterine 
cavities  is  very  rare.  In  such  cases,  the  foetus  may  be  expelled 
through  one  rent,  and  the  placenta  through  the  other  (Webster). 

Isthmial  Pregnancy. 

In  an  isthmial  pregnancy,  the  ovum  becomes  implanted, 
and  develops,  in  the  middle  third  of  the  tube.  As  the  ovum 
grows,  the  tube  wall  thins,  and  the  peritoneal  folds  which  form 
the  broad  ligament  are  separated  from  one  another.  In  almost 
every  case,  rupture  occurs  before  the  end  of  the  third  month, 
and  usually  between  the  sixth  and  tenth  week,  but  a  few  cases 

*  Op.  cit.,  p.  77. 

f  '  Beitriige  z.  Lehre  von  d.  Schwangerschaft,'  etc.,  Mounts,  f.  Gebnrts., 
1S59,  vol.  xiii. 


650 


THE  PATHOLOGY  OF  PREGNANCY 


have  been  recorded  in  which  pregnancy  went  to  full  term  with- 
out an  apparent  rupture  of  the  tube  occurring.  When  rupture 
occurs,  the  tear  may  be  so  situated  that  the  ovum  escapes  into 
the  peritoneal  cavity  or  between  the  layers  of  the  broad  ligament. 
Usually,  the  rent  is  not  very  large,  and  the  ovum  gradually  works 
its  way  through  it.  In  other  cases,  however,  it  may  be  of 
sufficient  size  to  allow  the  immediate  passage  of  the  ovum.  The 
consequences  of  intra-peritoneal  rupture  will  be  discussed  in  the 
sections   on    ampullar    pregnancy,    as    it    is    of    more   common 


UC 


LT 


RT 


RO 


Fig.  291. — An  Interstitial  Pregnancy  at  about  the  Fourth  Month. 

O,   Cavity  of  the  ovum;    P,  placenta;    RT,   right  tube;    RO,  right  ovary; 
LT,  left  tube  ;  UC,  uterine  cavity  ;   C,  cervix.     (Bumm). 

occurrence  in  this  condition,  and  as  its  symptoms  are  identical  in 
whatever  part  of  the  tube  the  ovum  is  situated. 

Extra-peritoneal  Rupture. — The  occurrence  of  extra-peritoneal 
rupture  of  the  tube,  that  is,  rupture  between  the  layers  of  the  broad 
ligament,  is  practically  confined  to  cases  of  isthmial  pregnancy. 
In  such  a  case,  the  ovum  may  be  already  dead — a  mole  having 
formed ;  the  attachments  of  the  ovum  to  the  tube  may  be  broken 
down  at  the  time  of  rupture,  and  the  ovum  may  die  ;  or,  the  attach- 
ments may  not  be  interfered  with,  and  the  ovum  may  live.   Further, 


EXTRA-PERITONEAL  RUPTURE  OF  THE  TUBE  651 

the  haemorrhage  which  accompanies  rupture  may  be  checked  by 
the  pressure  of  the  peritoneal  folds  of  the  broad  ligament,  and 
so  may  be  comparatively  slight  in  amount,  or  the  haemorrhage 
may  burrow  under  the  peritoneum  of  the  pelvic  floor  and  spread 
through  the  pelvic  connective  tissue. 

When  the  ovum  is  either  already  dead  or  dies  at  the  time  of 
rupture,  and  the  haemorrhage  does  not  extend  beyond  the  broad 
ligament,  the  resulting  condition  is  known  as  a  haematoma  of  the 
broad  ligament.  In  this  condition,  the  blood  coagulates  and 
forms  a  firm  tumour,  which,  if  of  large  size,  pushes  the  uterus  to 
the  opposite  side,  or  bulges  backwards  into  Douglas's  pouch  and 
pushes  the  uterus  forwards  as  in  the  case  of  a  haematocele.  As  a 
rule,  the  coagulated  blood  is  gradually  absorbed  aseptically,  with- 
out further  trouble.  Occasionally,  however,  bacteria  may  find 
their  way  into  the  haematoma  from  the  intestines  and  set  up 
decomposition  or  pus-formation.  The  resulting  abscess  will  then 
behave  in  a  manner  similar  to  a  suppurating  haematocele. 

In  the  rare  cases  in  which  the  escaping  blood  burrows  beyond 
the  broad  ligament,  it  may  make  its  way  beneath  the  perito- 
neum of  Douglas's  pouch,  and  extend  round  the  rectum,  or 
bladder,  or  downwards  beside  the  vagina.  It  may  also  extend 
upwards  beneath  the  peritoneum  of  the  anterior  abdominal  wall, 
or  along  the  psoas  and  iliacus  muscles.  In  such  cases,  the 
amount  of  blood  lost  may  be  so  great  as  to  cause  the  death  of  the 
patient. 

The  most  important  termination  of  extra-peritoneal  rupture 
consists  in  the  gradual  passage  of  the  living  ovum  between  the 
layers  of  the  broad  ligament.  To  this  condition,  the  term 
secbndary  broad  ligamentous  or  meso-metric  pregnancy  is  applied. 
As  the  ovum  passes  through  the  rent  in  the  tube,  it  comes  to  lie 
in  a  sac  formed  above  by  the  dilated  tube,  and  laterally  by  the 
peritoneal  layers  of  the  broad  ligament.  As  the  ovum  grows,  the 
relations  of  the  peritoneum  to  the  pelvic  floor  and  to  the  walls 
of  the  abdominal  cavity  become  altered.  At  first,  the  peri- 
toneum of  the  broad  ligament  is  pushed  upwards,  and  separated 
laterally  as  far  as  its  amount  and  elasticity  permit.  Then, 
in  order  to  allow  further  increase  in  size,  the  peritoneum 
of  the  floor  of  the  pelvis  is  stripped  off  and  included  in  the 
covering  of  the  tumour.  Finally,  this  stripping  extends  to  the 
anterior  and  posterior  pelvic  walls,  and  then  to  the  abdominal 
walls.  In  a  case  recorded  by  Berry  Hart,  in  which  the  patient 
died  undelivered  at  full  term,  the  peritoneum  was  stripped  off  the 
anterior  abdominal  wall  for  a  distance  of  7§  inches  above  the 
pelvic  brim,  and  posteriorly  up  to  the  level  of  the  junction  of  the 
fourth  and  fifth  sacral  vertebrae.  This  stripping  of  the  peritoneum 
is  a  point  of  considerable  importance  from  an  operative  point  of 
view,  as  will  be  subsequently  seen.  The  degree  to  which  it  occurs 
probably  depends  on  the  natural  strength  of  the  peritoneum,  and 
on  the  strength  of  its  attachments  to  the  sub-peritoneal  tissues. 


652  THE  PATHOLOGY  OF  PREGNANCY 

In  the  majority  of  cases,  either  the  former  is  too  weak  or  the 
latter  too  strong  to  allow  the  peritoneum  to  stand  the  strain 
which  the  growing  ovum  places  on  it,  the  necessary  degree  of 
stripping  does  not  occur,  and,  consequently,  secondary  rupture  of 
the  gestation  sac  occurs  about  the  middle  of  pregnancy.  The 
consequence  of  this  rupture  will  almost  certainly  be  the  death  of 
the  patient  from  haemorrhage,  unless  immediate  operation  is 
undertaken.  In  some  cases,  however,  the  necessary  degree  of 
stripping  occurs,  and  the  pregnancy  advances  to  term  without 
secondary  rupture  occurring. 

Berry  Hart*  has  rendered  great  service  by  pointing  out  the 
importance  of  the  relation  of  the  placenta  to  the  displaced  ovum 
in  these  cases.  If  the  placenta,  or  in  the  early  months  of 
pregnancy  that  part  of  the  chorionic  villi  from  which  the  placenta 
will  subsequently  be  formed,  is  situated  above  the  ovum,  the 
extra-peritoneal  rupture  of  the  tube  will  not  affect  it,  and  con- 
sequently the  ovum  has  the  best  immediate  chance  of  living. 
The  remote  consequences  are,  however,  very  much  more  serious 
both  for  the  foetus  and  the  mother  than  they  are  in  cases  in  which 
the  placenta  is  situated  below  the  ovum.  When  the  placenta  is 
above  the  foetus,  the  latter  burrows  downwards  between  the 
layers  of  the  broad  ligament  until  it  has  occupied  all  the  available 
space.  Then,  it  of  necessity  exerts  an  upward  pressure  upon  the 
placenta  and  the  latter  is  displaced  upwards.  In  such  cases,  as 
the  placenta  grows,  it  extends  over  the  displaced  peritoneum,  and 
perhaps  on  to  the  anterior  abdominal  wall  from  which  the  peri- 
toneum has  been  stripped.  During  this  stage,  repeated  extra- 
vasations of  blood  occur,  and  cause  a  varying  degree  of  destruc- 
tion of  the  placental  tissue.  Later,  if  secondary  rupture  of  the 
gestation  sac  occurs,  the  tear  will  involve  the  placenta,  or  the 
large  vessels  which  supply  the  latter,  and  the  haemorrhage  will  be 
so  serious  as  to  prove  almost  immediately  fatal. 

When  the  placenta  lies  below  the  foetus,  the  latter,  as  it  grows, 
pushes  the  placenta  downwards  against  the  pelvic  floor.  Here, 
it  has  a  firm  base  of  attachment,  and  can  extend  on  to  the 
surrounding  structures  without  risk  of  subsequent  displacement. 
Further,  even  if  secondary  rupture  of  the  sac  occurs,  the 
consequences  are  not  so  serious  owing  to  the  non-involvement 
of  the  placental  vessels. 

Secondary  rupture  of  a  broad  ligamentous  pregnancy  may 
occur  at  any  time  from  the  twelfth  week  onwards,  and  perhaps 
most  usually  occurs  about  the  fifth  month.  The  rupture  is  said 
to  be  most  usually  situated  in  the  posterior-superior  portion  of 
the  sac  wall  (Werth).  If  the  placenta  lies  above  the  foetus, 
the  rupture  is  almost  certainly  fatal  owing  to  violent  haemorrhage. 
If  the  placenta  is  below  the  foetus,  the  haemorrhage  may  be  slight, 
and  afford  time  for  operation  ;  or,  if  the  rupture  occurs  gradually 
in  a  non-vascular  portion  of  the  sac,  the  ovum  may  slowly  pass 
*  Edin.  Med.  Journ. ,  vol.  xxxiii.,  p.  322. 


INTRAPERITONEAL  RUPTURE  OF  THE  TUBE  653 

through  it  into  the  peritoneal  cavity  as  in  some  cases  of  primary 
intra-peritoneal  rupture  of  the  tube.  In  such  an  event,  the  sub- 
sequent history  of  the  case  is  identical  with  that  of  primary 
intra-peritoneal  rupture  in  which  the  ovum  survives,  and  will  be 
discussed  later. 

In  those  cases  in  which  secondary  rupture  does  not  occur,  the 
foetus  dies  at  full  term,  and  one  or  other  of  the  various  changes 
to  which  we  have  already  referred,  occurs  in  the  ovum. 

Ampullar  Pregnancy. 

In  an  ampullar  pregnancy,  the  ovum  becomes  implanted  in 
the  outer  third  of  the  tube.  If  it  is  situated  close  to  the  abdomina 
ostium,  the  condition  is  further  specified  as  an  infundibular  preg- 
nancy. As  the  ovum  grows,  the  tube  distends,  but,  inasmuch 
as  the  ampulla  is  almost  completely  invested  by  peritoneum, 
there  is  no  tendency  for  the  peritoneal  layers  of  the  broad  ligament 
to  be  forced  apart.  Consequently,  when  rupture  occurs  the  ovum 
always  escapes  into  the  peritoneal  cavity. 

There  are  three  possible  terminations  of  a  case  of  ampullar 
pregnancy.  First,  and  most  commonly,  intra-peritoneal  rupture 
may  occur.  Secondly,  and  also  fairly  commonly,  tubal  abortion 
may  occur  and  the  ovum  be  expelled  in  part  or  altogether  through 
the  abdominal  ostium  into  the  peritoneal  cavity.  Lastly,  and  very 
rarely,  the  tube  may  dilate  sufficiently  to  enable  it  to  accommodate 
the  ovum  up  to  full  term  without  rupturing.  The  last  of  these 
three  terminations  does  not  call  for  any  special  remark.  Clinically, 
it  would  probably  be  difficult  to  distinguish  such  a  case  from 
one  of  broad  ligamentous  pregnancy,  as  the  symptoms  and 
consequences  of  the  two  are  practically  identical.  The  first 
two  terminations  must  be  discussed  separately. 

Intra-peritoneal  Rupture. — Intra-peritoneal  rupture,  as  we  have 
seen,  may  be  either  primary  or  secondary.  Primary  rupture 
occurs  when  the  tube  ruptures,  and  the  ovum  is  expelled  directly 
into  the  peritoneal  cavity.  Such  a  termination  may  occur  in  any 
form  of  tubal  pregnancy — interstitial,  isthmial,  and  ampullar,  and, 
in  all,  the  results  so  far  as  the  patient  and  ovum  are  concerned 
are  similar.  Secondary  rupture  occurs  when  a  broad  ligamentous 
pregnancy — the  result  of  a  primary  extra-peritoneal  rupture  of 
the  tube — in  turn  ruptures  into  the  peritoneal  cavity. 

It  may  be  well  to  repeat  that  in  cases  of  secondary  rupture, 
the  primary  extra-peritoneal  rupture  will  most  usually — if  not 
always — have  escaped  notice,  as,  if  the  symptoms  produced  were 
marked,  the  death  of  the  ovum  would  almost  certainly  have 
occurred,  and  consequently  there  would  have  been  no  such  thing 
as  a  secondary  rupture. 

The  usual  time  at  which  intra-peritoneal  rupture  occurs  is 
from  the  sixth  to  the  tenth  week  in  the  primary  form,  and  during 
the  fourth,  fifth,  and  sixth  months  in  the  secondary  form.     The 


654 


THE  PATHOLOGY  OF  PREGNANCY 


following  table  is  compiled  from  a  number  of  statistics  collected 
by  Webster*  : — 


Date  of  Rupture. 

Number  of 
Cases. 

Date  of  Rupture. 

Number  of 
Cases. 

ist  month     - 

2nd     ,, 

3rd 

4th      ,, 

5*      ,,          -         - 

6th      ,, 

39 

141 

74 

49 

8 

1 

7th  month    - 

8th      ,, 

9th  ,, 
10th  ,, 
After  10th  month  - 

1 
6 
1 

9 
1 

Total  number  of  cases     -         -     330 

One  of  three  consequences  are  possible  in  cases  of  intra- 
peritoneal rupture.  The  haemorrhage  may  be  profuse  and  be 
poured  out  into  the  general  abdominal  cavity — diffuse  haemorrhage ; 
the  haemorrhage  may  be  moderate  in  amount  and  collected  in 
Douglas's  pouch,  where  it  clots  and  forms  a  retro-uterine 
haematocele  ;  the  haemorrhage  may  be  insignificant  in  amount, 
and  the  ovum  may  continue  to  develop. 

Diffuse  haemorrhage  is  the  most  serious  consequence,  and 
inevitably  results  in  the  patient's  death  within  twenty  -  four 
hours,  unless  immediate  operation  is  performed  and  the  bleeding 
checked.  If  the  abdomen  is  opened,  the  peritoneal  cavity  is 
found  to  contain  a  variable  quantity  of  free  blood  and  clots, 
and,  in  many  cases,  it  is  possible  to  find  the  foetus  or  mole 
which  has  been  expelled  from  the  tube.  In  cases  of  secondary 
rupture,  it  is  always  possible  to  do  so  on  account  of  the  greater 
size  of  the  ovum.  The  amount  of  haemorrhage  which  occurs 
depends  upon  the  age  of  the  pregnancy,  and,  in  secondary 
ruptures,  the  relations  of  the  placenta  to  the  gestation  sac.  In 
primary  rupture,  the  ovum  may  be  entirely  separated  and  expelled 
from  the  tube.  In  secondary  rupture,  on  the  other  hand,  the 
placenta  may  be  torn  through,  but  it  will  still  remain  in  great 
part  adherent  to  its  site. 

The  formation  of  a  retro-uterine  haematocele  is  probably 
dependent  upon  the  rate  at  which  the  haemorrhage  occurs.  If  it 
escapes  slowly,  but  is  persistent  or  recurrent,  the  escaped  blood 
has  time  to  clot  round  the  site  of  rupture.  As  fresh  haemorrhage 
occurs,  the  clotted  blood  is  pushed  outwards  away  from  the 
rupture,  and  its  place  is  taken  by  fresh  blood,  which  in  turn  clots 
and  is  pushed  outwards.  Finally,  the  clotted  blood  in  the  outer 
layers  becomes  too  firm  to  allow  any  further  displacement,  and 
then  the  haemorrhage  is  stopped  by  the  increased  pressure  in  the 
centre  of  the  mass  of  clot.  In  other  cases,  the  formation  of  a 
haematocele  may  be  brought  about  by  the  presence  of  adhesions 
which    prevent  the  upward   escape  of   blood   and    confine  it  to 


*  Op.  cit.,  p.  63. 


INTRAPERITONEAL  RUPTURE  OF  THE  TUBE 


655 


Douglas's  pouch.  The  same  train  of  events  may  occur  in  cases 
of  tubal  abortion,  as  will  be  presently  seen,  and  is  perhaps  more 
common  in  that  condition  than  in  tubal  rupture,  in  consequence 
of  the  more  gradual  manner  in  which  the  blood  usually  escapes. 
The  formation  of  a  haematocele  is  probably  confined  to  cases  of 
primary  rupture,  and  to  cases  of  secondary  rupture  occurring  early 
in  pregnancy.  In  a  hematocele,  the  blood  first  collects  round 
the  opening  through  which  the  ovum  has  been  expelled,  and  then 
makes  its  way  into  Douglas's  pouch.     If  it  reaches  a  large  size, 


Fig.  292. — A  Retro-uterine  Hematocele  formed  by  the  Rupture  of  a 
Left-sided  Tubal  Pregnancy. 

F,  Fundus  uteri  ;  RT,  right  tube  ;  H,  haematocele  ;  C,  caecum  ;  A,  appendix  ; 
S,  sigmoid  flexure ;  LT,  left  tube  ;  IT,  isthmus  of  left  tube  ;  F,  tubal 
fimbriae  ;  O,  site  of  rupture  in  tube.     (Bumm.) 


it  may  extend  high  up  into  the  abdomen.  At  first,  it  is  soft  and 
boggy  in  consistency,  with  a  dome-shaped  top.  It  displaces  the 
uterus  usually  forwards,  but  sometimes  it  may  drive  the  latter 
backwards  or  surround  it  completely.  At  first,  a  haematocele 
compresses  the  rectum  against  the  wall  of  the  pelvis,  and,  later, 
as  the  effused  blood  coagulates  and  the  periphery  of  the  mass 


656  THE  PATHOLOGY  OF  PREGNANCY 

becomes  hard,  it  surrounds  the  upper  part  of  the  rectum  as  a  firm 
collar,  which  often  causes  a  temporary  stricture.  In  the  past,  it 
was  customary  to  consider  that  only  a  small  proportion  of  cases 
of  hsematocele  were  due  to  extra-uterine  pregnancy.  This  view, 
however,  can  no  longer  be  adopted,  and,  on  the  contrary,  it  is 
almost  certain  that  it  is  only  a  very  small  proportion  of  cases  of 
hematocele  which  are  not  so  caused. 

In '  the  case  of  a  large  hsematocele,  the  patient  may  die  in 
consequence  of  the  loss  of  blood,  but  such  an  occurrence  is 
unusual.  A  small  or  medium-sized  haematocele  is  usually 
absorbed,  and  may  almost  completely  disappear.  Lastly,  any 
hsematocele  may  be  infected  from  the  intestines  and  undergo  de- 
composition and  suppuration.  If  the  foetus  is  very  small,  it  will 
probably  share  the  fate  of  the  haematocele.  If,  however,  the 
foetus  is  too  large  for  absorption,  it  will  undergo  one  of  the 
changes  which  have  been  already  referred  to.  When  suppura- 
tion occurs,  and  an  abscess  forms,  the  pus  will  eventually  make 
its  way  externally,  owing  to  the  abscess  bursting,  usually  into  the 
vagina  or  rectum,  more  rarely  into  the  bladder,  or  intestine,  or 
through  the  abdominal  wall. 

The  third  and  last  consequence  of  intra- peritoneal  rupture  is 
the  gradual  extension  of  the  ovum  into  the  peritoneal  cavity, 
without  interference  with  its  attachments  to  the  gestation  sac, 
and  without  the  occurrence  of  serious  haemorrhage.  The  possi- 
bility of  the  ovum  surviving  primary  intra-peritoneal  rupture  has 
been  strongly  denied  by  Bland-Sutton*  and  by  Tait,f  mainly  on 
the  ground  that  the  amniotic  sac  is  always  torn,  and  that  an  un- 
protected embryo  in  the  peritoneal  cavity  would  be  quickly 
absorbed.  The  second  part  of  this  statement  is  probably  true, 
but  cases  have  been  recorded  which  appear  to  prove  beyond 
doubt  that  primary  intra-peritoneal  rupture  of  the  tube  can  occur 
without  an  accompanying  rupture  of  the  amnion,  and  that  in 
some  of  such  cases  the  ovum  can  survive  and  develop  to  full 
term  (Taylor,  J  Webster §).  In  cases  of  secondary  rupture  of  a 
broad  ligamentous  pregnancy,  the  foetus  has  usually  reached  such 
a  stage  of  development  that  it  is  able  to  resist  the  absorptive 
properties  of  the  peritoneum,  and,  consequently,  even  if  it  is 
expelled  unprotected  into  the  peritoneal  cavity,  it  may  still 
continue  to  develop.  In  cases  of  primary  intra-abdominal 
rupture  in  which  the  ovum  survives,  the  principal  attachment  of 
the  placenta  is  usually  to  a  dilated  Fallopian  tube,  and  from  there 
it  has  spread  to  the  neighbouring  parts,  and  so  may  be  adherent 
to  the  surface  of  the  uterus,  or  to  parts  of  the  intestines.  The 
relations  of  the  placenta  at  term  in  cases  of  secondary  intra- 
abdominal rupture  have  been  already  described.  Invariably,  in 
cases  in  which  the  ovum  has  survived  the  rupture,  the  placenta 
lies    below   the   foetus    and    has   its    main    attachment    to    the 

*  Op.  cit.  f  '  Lectures  on  Ectopic  Pregnancy,'  p.  59. 

X  Op.  cit.  §  Op.  cit. 


TUBAL  ABORTION  657 

pelvic  floor,  where  it  may  extend  over  the  anterior  or  posterior 
abdominal  walls  from  which  the  peritoneum  has  been  stripped. 
The  death  of  the  foetus  occurs  at  or  soon  after  term  has  been 
reached,  and  then  one  or  other  of  the  different  changes  which 
have  been  already  referred  to  take  place. 

Tubal  Abortion. — The  second  common  termination  of  a  case  of 
ampullar  pregnancy  is  the  occurrence  of  tubal  abortion  (v.  Fig.  293). 
This  is  the  most  usual  ending  of  those  cases  in  which  the  ovum 
is  implanted  in  the  infundibulum  of  the  tube — the  so-called  infundi- 
bular or  tubo-peritoneal  pregnancy,  as  in  such  cases  the  growing 
ovum  prevents  the  abdominal  ostium  from  closing.  It  is  also 
possible  that,  even  in  cases  where  the  ostium  has  partially  closed, 
its  dilatation  may  be  effected  by  the  pressure  of  the  growing 
ovum,  which  may  then  be  expelled  through  the  ostium. 

Tubal  abortion  most  usually  occurs  during  the  first  or  second 
month.      Out  of   sixty-one  cases  recorded   by   Mackenrodt    and 


O  F 

Fig.   293. — A  Tubal  Abortion. 

O,  Ovum  in  process  of  expulsion  ;  F,  dilated  abdominal  ostium  ;   A,  ampulla 
of  tube  ;   I,  isthmus  of  tube.     (Bumm.) 

Martin,  abortion  occurred  in  twenty-one  cases  in  the  first  month, 
in  twenty-nine  cases  in  the  second  month,  in  eight  cases  in  the 
third,  and  in  three  cases  in  the  fourth.  The  entire  ovum  may 
be  expelled,  or  it  may  still  remain  in  part  adherent  to  the  tube. 
Its  expulsion  is  probably  due  to  the  contraction  of  the  muscular 
coat  of  the  tube,  or  to  the  accumulation  of  blood  at  the  proximal 
side  of  the  ovum,  an  accumulation  which,  as  it  increases,  gradually 
pushes  the  ovum  in  the  direction  of  least  resistance.  It  is  prob- 
able that,  in  the  majority  of  cases  of  tubal  abortion,  the  ovum 
has  become  converted  into  a  mole  either  before  the  abortion  com- 
mences or  whilst  it  is  in  process.  In  some  cases,  however,  an 
uninjured  ovum  may  be  thus  expelled. 

The  consequences  of  tubal  abortion  are  very  similar  to  those  of 
intra-peritoneal  rupture,  but,  as  a  rule,  the  haemorrhage  occurs 
more  gradually,  and,  in  consequence,  the  formation  of  a  haematocele 
is  relatively  more  common   than  in   the  case  of  tubal   rupture. 

42 


658 


THE  PATHOLOGY  OF  PREGNANCY 


Even  if  such  is  the  termination  of  the  case,  the  mother  may  die 
in  consequence  of  the  steady  persistence  of  the  haemorrhage, 
especially  in  cases  in  which  the  ovum  still  remains  partially 
adherent  to  the  tube. 


Cornual  Pregnancy. — A  few  words  must  be  said  here  on  the 
subject  of  pregnancy  occurring  in  the  rudimentary  horn  which 
may  be  found  in  association  with  a  uterus  bi-cornis.  Such  a 
pregnancy  is  extremely   rare,    so   much    so  that,   in   1888,  only 


THE  CLINICAL  ASPECT  OF  EXTRA-UTERINE  PREGNANCY    659 

thirty-lour  cases  were  known  (Himmelfarb").  The  course  of  cornual 
pregnancy  is  practically  the  same  as  that  of  tubal  pregnancy.  In 
the  great  majority  of  cases,  rupture  occurs,  usually  accompanied 
by  haemorrhage,  which  proves  fatal  unless  checked.  In  rare 
instances,  the  ovum  may  continue  to  develop.  The  period  at 
which  rupture  occurs  is  dependant  upon  the  degree  to  which  the 
cornu  has  developed. 

The  relations  of  the  rudimentary  cornu  to  the  well-developed 
cornu  render  it  difficult  at  first  sight  to  distinguish  a  case  in  which 
pregnancy  has  occurred  from  a  tubal  pregnancy,  even  on  post- 
mortem examination.  The  following  anatomical  relations  will, 
however,  usually  allow  a  diagnosis  to  be  arrived  at  (Websterf) : — 

(1)  In  infundibular  and  ampullar  pregnancies,  the  round  liga- 
ment is  found  attached  to  a  normal  uterus  on  the  uterine  side 
of  the  gestation  sac.  The  normal  appearance  of  the  Fallopian 
tube  is  greatly  altered,  owing  to  the  presence  of  the  ovum. 

(2)  In  cornual  pregnancy,  the  round  ligament  is  external  to  the 
gestation  sac.  The  unimpregnated  horn  differs  markedly  in 
shape  from  the  normal  uterus.  The  Fallopian  tube  is  found 
attached  to  the  pregnant  horn,  and  is  not  necessarily  altered. 
The  pregnant  rudimentary  horn  is  attached  to  the  opposite  well- 
developed  horn  at  the  upper  end  of  the  cervix. 

(3)  It  may  be  difficult  to  distinguish  an  interstitial  from  a 
cornual  pregnancy.  In  both  cases  the  round  ligament  is  external 
to  the  gestation  sac,  though  if  the  pregnancy  is  partly  interstitial, 
and  partly  isthmial,  it  may  be  attached  to  the  anterior  aspect  of 
the  sac.  The  close  incorporation  of  the  sac  with  the  rest  of  the 
uterus  and  the  absence  of  a  separate  horn  will  help,  however,  to 
distinguish  the  interstitial  from  the  cornual  pregnancy. 

The  Clinical  Aspect  of  Extra-uterine  Pregnancy. 

We  now  come  to  discuss  the  symptoms,  diagnosis,  and  treat- 
ment of  the  various  phases  of  extra-uterine  pregnancy,  and  in 
doing  so  we  shall  divide  the  pregnancy  into  three  periods,  each  of 
which  will  be  discussed  separately.     These  periods  are  : — 

(1)  Before  rupture  of  the  gestation  sac. 

(2)  At  the  time  of  rupture  of  the  gestation  sac. 

(3)  After  rupture  of  the  gestation  sac. 

Before  Rupture  of  the  Gestation  Sac — This  period 
commences  at  the  time  of  the  implantation  of  the  ovum  in 
the  tube,  and  ends  with  the  commencement  of  rupture  of  the 
gestation  sac.  We  have  already  pointed  out  that,  so  far  as 
the  symptoms  of  the  patient  are  concerned,  there  is  rarely  more 
than   one  rupture,  as,  if  the   symptoms  of  primary  rupture  are 

*   '  Ueber  Nebenhornschwangerschaft,'  Munch  en.  Med.    Wochen.,  1888,  Nos. 
17  and  18. 
t  Op.  tit.,  p.  87. 

42 — 2 


660  THE  PATHOLOGY  OF  PREGNANCY 

sufficient  to  draw  attention  to  the  nature  of  the  case,  either  the 
ovum  or  the  mother  will  die,  or  the  former  will  be  removed  by 
operation.  Consequently,  in  those  cases  in  which  secondary 
rupture  occurs,  the  first  rupture  has  caused  so  slight  symptoms 
that  its  occurrence  has  escaped  notice. 

Symptoms. — Special  symptoms,  which  might  serve  during  the 
first  period  of  extra-uterine  pregnancy  to  distinguish  between 
a  case  of  extra-  and  intra-uterme  pregnancy,  are  in  the  main 
characterised  by  their  absence.  In  many  cases,  there  is  nothing 
which  can  serve  to  direct  the  attention  of  either  the  patient  or  her 
medical  attendant  to  the  nature  of  the  case.  The  usual  symptoms 
of  pregnancy  are  present,  save  that  the  menstrual  history  may 
be  quite  atypical.  The  patient  may  give  the  usual  history  of 
amenorrhcea  ;  she  may  have  menstruated  regularly  up  to  the  date 
of  rupture  of  the  sac  ;  or,  she  may  have  menstruated  for  the  first 
couple  of  months,  and  then — in  a  case  where  the  occurrence  of  the 
primary  rupture  was  not  noticed — she  may  have  missed  two  or 
three  periods.  The  amount  and  nature  of  the  menstrual  flow  may 
be  normal,  or  it  may  be  very  slight  and  altered  in  character. 
Lastly,  the  patient  may  suffer  from  repeated  attacks  of  menor- 
rhagia,  or  from  an  almost  continuous  hemorrhagic  discharge.  In 
most  cases,  it  is  probable  that  the  haemorrhage  is  due  to  the 
detachment  of  small  pieces  of  the  decidua  which  forms  in 
the  uterine  cavity,  due  to  a  recurrent  monthly  congestion,  or 
to  degeneration  of  the  decidua.  More  rarely,  it  is  possible 
that,  in  cases  of  tubal  mole,  the  blood — in  part  at  any  rate — 
comes  from  the  tube.  Such  an  occurrence  is  of  course  only 
possible  if  the  tube  remains  patent  at  the  uterine  side  of  the 
ovum.  It  is  probable  that,  if  these  uterine  discharges  could  be 
examined,  in  most  cases  shreds  of  decidua  would  be  found  in 
them,  a  discovery  which  would  be  of  great  assistance  in  arriving 
at  a  diagnosis  of  the  nature  of  the  case.  In  some  cases,  a  com- 
plete decidua  is  expelled,  even  prior  to  the  occurrence  of  rupture. 

Irregular  and  intermittent  pains,  referred  to  the  lower  part  of 
the  abdomen  and  back,  are  of  relatively  common  occurrence. 
They  are  probably  due  to  contractions  of  the  uterus,  provoked  by 
the  presence  of  the  decidua,  and  may  possibly  be  sometimes 
caused  by  contractions  of  the  muscle  fibre  in  the  walls  of  the 
gestation  sac.  They  are  most  irregular  in  their  occurrence,  and 
in  some  cases  may  be  absent.  Similar  pains  are  also  of  not 
infrequent  occurrence  in  cases  of  intra-uterine  pregnancy. 

The  results  of  a  physical  examination  are  more  definite.  The 
usual  signs  of  pregnancy  are  to  be  found,  including  enlargement 
of  the  uterus.  The  latter,  however,  as  well  as  the  other  uterine 
phenomena  of  pregnancy,  are  not  so  well  marked  as  in  a  case  of 
intra-uterine  pregnancy.  In  a  favourable  case,  it  ought  to  be 
possible  to  detect  the  enlarged  tube  by  means  of  a  bi-manual 
examination  at  any  time  after  the  end  of  the  fourth  week.  It  is 
then  felt  as  an  oval  swelling  to  one  side   of  the  uterus  or   in 


THE  CLINICAL  ASPECT  OF  EXTRA-UTERINE  PREGNANCY     661 

Douglas's  pouch.  The  tumour  pulsates,  and  corresponds  in  size 
with  the  period  of  pregnancy.  In  a  case  of  interstitial  pregnancy, 
the  tumour  is  incorporated  with  the  uterus,  to  which  it  imparts 
an  asymmetrical  shape.  In  an  isthmial  pregnancy,  it  is  just 
possible  to  determine  that  the  swelling  is  not  incorporated  with 
the  uterus,  but  that  it  is  quite  distinct.  While,  in  an  ampullar 
pregnancy,  the  swelling  is  connected  with  the  uterus  by  a  pedicle, 
formed  of  the  remainder  of  the  tube,  and  consequently  has  a 
certain  range  of  motion,  unless  fixed  by  adhesions.  As  the  ovum 
increases  in  size,  the  position  of  the  uterus  is  altered.  It  is 
usually  displaced  to  the  opposite  side,  or  forwards,  according  as 
the  enlarged  tube  is  lying  to  one  or  other  side  of  the  uterus  or  in 
Douglas's  pouch.  When  the  tube  has  ruptured  into  the  broad 
ligament,  the  upper  part  of  the  vagina,  as  well  as  the  uterus,  may 
be  displaced  to  the  opposite  side.  In  such  cases,  it  may  also  be 
possible  to  obtain  internal  ballottement,  particularly  if  the 
placenta  happens  to  be  situated  above  the  fcetus.  If  it  is  below 
the  fcetus,  it  will  mask  the  ovum  to  such  an  extent  that  it  would 
be  impossible  to  feel  the  fcetus  from  below. 

Diagnosis. — The  diagnosis  of  an  extra-uterine  pregnancy  prior 
to  rupture  can  usually  be  made  with  reasonable  certainty,  once 
the  ovum  has  reached  a  sufficient  size  to  be  palpable,  provided 
that  the  symptoms  of  the  patient  lead  her  medical  attendant  to 
make  a  bi-manual  examination.  Unless  the  diagnosis  is 
obvious,  the  patient  should  in  all  cases  be  examined  under 
an  anaesthetic,  in  order  to  obtain  relaxation  of  the  abdominal 
muscles,  and  to  allow  a  more  complete  examination  to  be  made. 
Leaving  interstitial  pregnancy  on  one  side,  the  chief  points  on 
which  we  rely  are  the  presence  of  the  subjective  symptoms  of  preg- 
nancy with  perhaps  an  anomalous  menstrual  history,  and  of  the 
objective  symptoms  with  certain  alterations  in  those  furnished 
by  the  uterus.  The  latter  is  enlarged,  but  not  to  such  an  extent 
as  the  period  of  pregnancy  would  demand.  It  preserves  its 
normal  unimpregnated  shape,  instead  of  assuming  the  globular 
outline  characteristic  of  intra-uterine  pregnancy.  The  usual 
softening  of  the  cervix  is  but  slightly  marked,  and  the  softening 
of  the  lower  uterine  segment — Hegar's  sign  of  pregnancy — is 
absent.  A  swelling  can  be  felt  to  one  or  other  side  of,  or  behind, 
the  uterus,  corresponding  in  position  to  the  Fallopian  tube,  and  in 
size  to  the  period  of  pregnancy.  It  is  distinguished  from  other 
tubal  swellings  by  the  size  of  the  bloodvessels  which  run  in  con- 
nection with  it,  by  the  fact  that  it  is  unilateral,  and  that  in  some 
cases  at  least  it  is  fairly  movable.  If  rupture  into  the  broad 
ligament  has  already  occurred,  the  swelling  will  be  situated  in  the 
broad  ligament,  and  will  be  larger  than  the  period  of  pregnancy 
would  suggest,  on  account  of  the  usual  accompanying  extravasa- 
tion of  blood.  If  the  fourth  month  has  been  reached,  it  may  be 
possible  to  obtain  internal  ballottement. 

It  may  be  most  difficult  or  impossible  to  distinguish  between  an 


662  THE  PATHOLOGY  OF  PREGNANCY 

ampullar  pregnancy  and  a  small  ovarian  cyst,  particularly  in  cases 
in  which  the  fimbriated  extremity  of  the  tube  and  ovary  are  in 
apposition.  If  the  history  of  the  case  and  the  absence  of  the 
symptoms  of  pregnancy  are  not  in  themselves  sufficient  to  enable 
a  distinction  to  be  made,  it  may  be  possible  to  make  one  by  noting 
the  relation  of  the  ovarian  ligament  to  the  tumour,  but  more 
frequently  such  cases  will  only  be  cleared  up  by  means  of  an 
exploratory  cceliotomy.  Such  a  procedure  is  quite  justifiable,  as 
whether  the  case  is  one  of  tubal  pregnancy  or  of  ovarian  tumour, 
the  swelling  requires  to  be  removed. 

Treatment. — The  treatment  of  these  cases  can  be  given  in  a  very 
few  words.  As  soon  as  the  nature  of  the  case  is  recognised,  or 
even  before  it  has  been  recognised,  if  there  is  reasonable  cause 
for  believing  that  the  case  is  one  of  extra-uterine  pregnancy,  the 
abdomen  must  be  opened  and  the  tube  containing  the  ovum 
removed.  The  abdomen  may  be  opened  by  either  the  ventral  or 
the  vaginal  route,  but,  in  the  majority  of  cases,  the  former  route 
is  preferable.  In  many  cases,  however,  the  operation  may  be 
easily  performed  by  the  vaginal  route.  If,  however,  the  ovum  has 
passed  into  the  broad  ligament,  the  abdominal  route  should  be 
always  chosen,  as  it  enables  a  more  full  view  to  be  obtained  of 
the  field  of  operation. 

■  The  steps  of  the  operation  do  not  call  for  description,  save  in 
the  case  of  a  broad  ligamentous  pregnancy,  in  which  very  great 
difficulties  may  arise  in  consequence  of  the  presence  of  the  placenta. 
The  procedures  which  are  adopted  at  this  period  of  pregnancy 
are,  however,  almost  identical  with  those  which  are  adopted  in 
cases  that  go  to  term,  and,  consequently,  we  shall  postpone  their 
description  until  we  are  discussing  the  latter  cases. 

All  such  procedures  as  the  injection  of  morphia  into  the  foetus, 
or  the  use  of  strong  electrical  currents,  with  the  object  of  killing 
the  foetus,  must  be  unhesitatingly  condemned.  They  are  both 
dangerous  and  uncertain  in  their  action,  and,  consequently,  have 
no  place  in  the  modern  treatment  of  extra-uterine  pregnancy. 

At  the  Time  of  Rupture  of  the  Gestation  Sac — This 
period  includes  the  occurrence  of  rupture  of  the  gestation  sac, 
either  primary  or  secondary,  whichever  is  of  clinical  importance. 
It  must  be  remembered  that  in  some  cases,  clinically,  this  period 
is  not  met  with,  as  primary  rupture  may  give  rise  to  no  special 
symptoms,  and  secondary  rupture  may  not  occur. 

Symptoms. — The  two  chief  symptoms  to  which  rupture  of  the 
gestation  sac  gives  rise  are  haemorrhage  and  pain.  These  are 
common  to  every  case,  but  their  degree  of  intensity  depends  upon 
the  nature  and  consequences  of  the  rupture.  There  is  also,  in 
almost  every  case,  a  haemorrhagic  discharge  from  the  uterus, 
accompanied  by  the  expulsion  of  a  complete  decidual  cast  of  the 
uterus  or  of  fragments  of  decidua. 

We  must  return  for  a  moment  to  what  has  been  already  said 


THE  CLINICAL  ASPECT  OF  EXTRA-UTERINE  PREGNANCY     663 

regarding  the  consequences  of  tubal  rupture.  Rupture  may  be 
intra-peritoneal  or  extra-peritoneal.  The  occurrence  of  the  former 
may  lead  to  diffuse  haemorrhage  into  the  peritoneal  cavity,  or  to 
the  formation  of  a  pelvic  hematocele  ;  the  occurrence  of  the  latter 
may  lead  to  diffuse  sub-peritoneal  haemorrhage,  or  to  the  formation 
of  a  haematoma  of  the  broad  ligament.  In  cases  of  secondary 
rupture  into  the  broad  ligament,  it  is  probable  that  the  haemor- 
rhage is  always  diffuse. 

As  is  to  be  expected,  diffuse  intra-peritoneal  haemorrhage  gives 
rise  to  very  serious  symptoms.  In  consequence  of  the  blood  lost, 
the  patient  becomes  collapsed,  and  blanched,  with  usually  a  rapid 
and  thready  pulse,  and  a  falling  temperature.  She  is  extremely 
restless,  and  wears  an  anxious  expression.  If  a  very  large 
quantity  of  blood  is  lost,  her  respirations  become  rapid  and  sigh- 
ing, and  she  seems  unable  to  obtain  sufficient  air — '  air-hunger.' 
Occasionally,  the  onset  of  the  haemorrhage,  if  gradual,  is  marked 
by  slowing  of  the  pulse.  The  occurrence  of  pain  is  very  marked. 
At  the  moment  rupture  occurs,  the  patient  may  complain  of  a 
sensation  as  if  something  had  torn  internally,  and  this  is  succeeded 
by  a  continuous  and  violent  abdominal  pain.  In  some  cases, 
this  is  so  severe  that  it  may  be  difficult  to  determine  whether 
the  accompanying  collapse  may  not  be  due  altogether  to  it.  The 
abdomen  is  also  usually  tympanitic  and  tender. 

Bi-manual  examination  in  the  case  of  rupture  occurring  before 
the  end  of  the  third  month  will  furnish  little  or  no  information. 
If  the  presence  of  a  tumour  to  one  or  other  side  of  the  uterus 
has  been  ascertained  beforehand,  it  may  be  possible  to  deter- 
mine its  disappearance,  and  at  the  same  time  to  recognise  the 
fact  that  the  uterus  is  enlarged.  Bi-manual  examination,  and 
abdominal  palpation,  should  be  avoided  as  much  as  possible, 
unless  we  are  prepared  to  open  the  abdomen  immediately,  as,  by 
interfering  with  the  formation  of  adhesions,  and  the  clotting  of  the 
blood  round  the  site  of  rupture,  these  procedures  may  remove  the 
slight  chance  which  Nature  affords  of  checking  the  haemorrhage. 
Moreover,  the  distended  and  tender  condition  of  the  abdomen 
usually  renders  it  impossible  to  obtain  any  information  of  value. 
The  same  remark  applies  to  the  performance  of  percussion  in 
different  positions  of  the  patient  with  the  object  of  detecting  altera- 
tions of  position  in  the  fluid.  It  is  possible  that,  if  a  very  large 
quantity  of  blood  has  escaped,  we  may  obtain  dulness  in  the  flanks 
changing  very  slowly  with  change  of  position  (Mayo  Robson*), 
but,  if  such  a  quantity  of  blood  has  escaped,  the  surgeon  has  not 
time  to  spend  in  such  formalities.  On  the  other  hand,  in  rupture 
occurring  after  the  formation  of  the  placenta  it  will,  usually,  be 
possible  to  determine  the  presence  of  the  ovum,  either  by  ab- 
dominal or  vaginal  examination. 

If  a  haematocele  is  forming,  the  symptoms  of  the  patient  are  not 
so  intense  as  they  are  in  cases  of  diffuse  haemorrhage,  inasmuch 
*  '  Ectopic  Pregnancy,'  Medical  Press  and  Circular,  January  25,  1898. 


664  THE  PATHOLOGY  OF  PREGNANCY 

as  the  haemorrhage  is  gradual.  If  the  hematocele  has  formed,  it 
will  be  possible  to  determine  its  presence  by  a  bi-manual  examina- 
tion. In  such  cases,  a  large  boggy  tumour  will  be  found  in 
Douglas's  pouch.  Below,  this  tumour  fills  the  pouch  exactly  and 
causes  it  to  bulge  downwards  and  forwards  into  the  vagina.  Above, 
it  is  dome-shaped,  but  the  outline  may  be  obscured  by  the  presence 
of  adherent  intestines.  If  the  finger  is  passed  into  the  rectum, 
the  latter  is,  in  the  early  stages,  flattened  out.  Later,  as  the 
blood  coagulates,  the  upper  part  of  the  rectum  is  invested  by 
a  hard  ring  of  coagulated  blood  which  almost  completely  sur- 
rounds it.  The  uterus  is  usually  displaced  forwards,  but  in  the 
rare  cases  in  which  it  was  retroverted  before  the  occurrence  of 
haemorrhage,  it. may  be  displaced  still  further  backwards. 

The  symptoms  of  diffuse  sub-peritoneal  haemorrhage  are  in  the 
main  similar  to  those  of  diffuse  intra-peritoneal  haemorrhage,  with 
the  association  of  pressure  symptoms  due  to  the  presence  of  blood 
beneath  the  pelvic  peritoneum.  Collapse  occurs  in  proportion  to 
the  amount  of  blood  lost.  Pain  in  these  cases  may  be  very  great, 
owing  to  the  disruption  of  the  tissues.  As  the  blood  clots,  compres- 
sion of  the  urethra  and  rectum  may  result,  giving  rise  to  difficulty 
in  micturition,  to  tenesmus,  and  to  partial  rectal  obstruction. 

The  symptoms  caused  by  the  formation  of  a  haematoma  in  the 
broad  ligament  are  usually  slight.  The  patient  may  or  may  not 
have  noticed  the  occurrence  of  a  sudden  pain  followed  by  faint- 
ness.  If  the  haematoma  is  large,  the  pain  may  continue.  On 
examination,  a  tumour  which  closely  resembles  a  unilateral  para- 
metritis is  found.  It  displaces  the  uterus  to  the  opposite  side,  and 
in  extreme  cases  may  extend  posteriorly  round  the  rectum. 

Diagnosis. — Rupture  of  the  gestation  sac  in  extra-uterine  preg- 
nancy has  to  be  diagnosed  from  the  different  phases  of  abortion, 
from  perforation  of  the  intestine,  and  from  rupture  of  any  other 
abdominal  or  pelvic  viscus  or  tumour.  Further,  a  retro-uterine 
haematocele  must  be  diagnosed  from  a  retroverted  pregnant  uterus, 
or — if  of  some  standing — from  a  case  of  double  salpingo-oophoritis ; 
and  a  haematoma  of  the  broad  ligament  must  be  diagnosed  from 
a  unilateral  parametritis.  The  diagnosis  between  extra-uterine 
pregnancy  and  abortion  must  be  fully  discussed,  but  this  will  be 
done  in  the  chapter  on  the  haemorrhages  of  pregnancy. 

The  diagnosis  from  perforation  or  from  rupture  of  any  other 
viscus  or  tumour  is  made  from  the  history  of  the  case,  which  will 
tend  to  show  the  existence  of  pregnancy,  and  the  non-existence 
of  any  condition  which  could  cause  perforation  or  rupture  else- 
where than  in  a  gestation  sac.  The  expulsion  of  a  decidua  will 
be  strong  proof  in  favour  of  pregnancy.  In  some  cases,  perfora- 
tion or  some  similar  condition  may  synchronise  with  the  occur- 
rence of  an  abortion,  and,  in  such  cases,  if  the  debris  which  has 
escaped  from  the  uterus  has  been  thrown  away,  the  diagnosis  will 
be  almost  impossible.  This  is,  however,  of  little  or  no  conse- 
quence, as  in  all  such  cases  where  it  is  obvious  that  something  has 


THE  CLINICAL  ASPECT  OF  EXTRA-UTERINE  PREGNANCY    665 

ruptured  into  the  peritoneal  cavity,  the  indication  is  to  open  that 
cavity  and  determine  what  exactly  has  ruptured.  Such  a  course 
is  correct  treatment,  but  to  waste  valuable  time  in  endeavouring 
to  make  an  exact  pre  operative  diagnosis  is  incorrect  treatment. 

The  diagnosis  between  a  recent  haematocele  and  a  retroverted 
pregnant  uterus  is  often  a  difficult  matter.  In  both  instances,  a 
bi  manual  examination  reveals  the  presence  of  a  tumour  filling  the 
pelvis,  displacing  the  upper  part  of  the  vagina  forwards,  and  com- 
pressing the  rectum  against  the  sacrum,  and  in  both  instances 
there  is  a  history  of  pregnancy.  The  points  by  which  a  diagnosis 
can  be  made  have  been  already  referred  to,  as  well  as  the  neces- 
sity for  making  a  correct  diagnosis  at  the  earliest  possible  moment. 
In  all  cases  of  doubt,  the  patient  should  be  examined  under  an 
anaesthetic,  and  if,  even  then,  a  diagnosis  cannot  be  arrived  at, 
it  may  be  necessary  to  pass  the  sound  into  the  uterus  to  determine 
its  position.  This  is,  of  course,  a  procedure  which  must  not  be 
resorted  to  unless  all  other  means  of  making  a  diagnosis  fail,  as, 
if  the  case  is  one  of  retroversion,  it  will  almost  certainly  cause  the 
expulsion  of  the  ovum.  It  is,  however,  better  to  adopt  such  a 
course  as  a  last  resource  rather  than  to  run  the  risks  of  attempting 
to  '  replace  '  a  haematocele,  or  to  leave  a  pregnant  uterus  in  a 
condition  of  incarceration. 

The  diagnosis  between  a  haematoma  of  the  broad  ligament  and 
a  unilateral  parametritis  can  be  made  from  the  history  of  the 
case  and  from  the  absence  of  high  temperature  or  other  febrile 
symptoms,  and  will  not  usually  present  any  difficulty. 

Treatment. — In  all  cases  of  diffuse  haemorrhage,  whether  intra- 
or  extra-peritoneal,  and  in  all  cases  in  which  the  haemorrhage  is 
continuing,  even  though  a  haematocele  may  be  in  process  of 
formation,  the  only  treatment  possible  consists  in  opening  the 
abdominal  cavity  and  ligating  and  removing  the  ruptured  tube. 
This  is  a  simple  procedure  in  cases  of  primary  rupture.  If,  how- 
ever, the  case  is  one  of  secondary  rupture  of  the  gestation  sac  at 
a  period  when  the  placenta  has  formed — i.e.,  after  the  commence- 
ment of  the  fourth  month — the  treatment  of  the  case  is  not  so 
simple.  It  will  be  referred  to  in  discussing  the  treatment  to  be 
adopted  after  the  occurrence  of  rupture,  when  we  shall  discuss 
the  subject  of  extra-peritoneal  gestation  generally. 

The  correct  treatment  of  a  pelvic  haematocele  cannot  be  so 
definitely  laid  down.  As  we  have  already  seen,  there  are  two 
terminations  possible  in  the  case  of  a  haematocele — the  blood  may 
be  absorbed  aseptically,  or  infection  may  take  place  and  an  abscess 
may  form.  It  is  unnecessary  to  operate  upon  the  cases  which 
would  be  absorbed,  but,  if  a  haematocele  which  has  been  left  alone 
subsequently  suppurates,  the  prognosis  is  worse  than  if  it  had 
been  operated  upon  before  suppuration  occurred.  The  principles 
of  treatment  are  quite  plain — if  a  haematocele  will  be  absorbed 
aseptically  let  it  alone,  if,  on  the  other  hand,  it  is  going  to  sup- 
purate remove  it ;  the  difficulty  is  to  apply  them,  as  we  can  never 


666  THE  PATHOLOGY  OF  PREGNANCY 

be  certain  what  will  be  the  subsequent  course  of  the  case.  We  do, 
however,  know  that  the  smaller  a  hematocele  is,  the  more  likely 
is  it  to  be  absorbed,  the  larger  it  is,  and  the  older  the  escaped 
ovum,  the  more  likely  it  is  to  suppurate.  Accordingly,  we  may 
regard  as  accepted  the  principle  that  every  large  hematocele,  no 
matter  what  the  age  of  pregnancy,  and  every  hematocele  in  which 
the  patient  was  more  than  three  months  pregnant,  should  be 
removed  at  the  earliest  date  possible,  and  by  a  large  hematocele 
we  mean  one  which  more  than  fills  Douglas's  pouch.  In  the  case 
of  small  hematoceles,  it  is  probable  that  every  operator  is  and 
will  be  governed  by  his  own  experiences,  and  results.  One 
operator  will  consider  it  advisable  to  operate  on  every  case  and 
remove  the  clots,  while  another  will  prefer  to  trust  to  absorption 
taking  place.  Which  line  of  treatment  is  best  can  only  be  decided 
by  statistics,  and  they  are  not  as  yet  available.  If  suppuration 
has  occurred,  or  if  there  is  evidence  of  its  commencement,  the 
remains  of  the  hematocele  should  be  immediately  removed. 

A  hematocele  can  be  removed  by  the  abdominal  route  or  by 
the  vaginal  route.  The  latter  is  certainly  the  correct  one  in  all 
cases  in  which  suppuration  has  occurred,  and  is  probably  the 
correct  route  in  all  cases.  An  opening  is  made  through  the 
posterior  vaginal  fornix  into  the  bottom  of  Douglas's  pouch,  and 
the  clots  are  removed  with  the  finger.  The  ovaries  and  tubes 
are  then  drawn  down  and  examined.  If  the  tube  is  found  to  be 
seriously  damaged,  it  must  be  removed.  In  cases  in  which  sup- 
puration is  commencing,  or  has  already  occurred,  great  care  must 
be  exercised  to  avoid  breaking  through  the  limiting  adhesions 
which  shut  the  hematocele  off  from  the  general  peritoneal  cavity. 
In  such  cases,  and  also  in  cases  in  which  there  is  persistent  oozing 
after  the  removal  of  a  non-suppurating  hematocele,  the  pelvis  is 
plugged  firmly  with  iodoform  gauze,  the  end  of  which  passes  into 
the  vagina.  This  gauze  is  removed  the  following  day.  In  aseptic 
cases,  there  is  no  necessity  to  replug  the  pelvis,  but  in  suppura- 
tive cases  the  pelvis  must  be  replugged  daily,  until  the  tempera- 
ture of  the  patient  and  the  cessation  of  purulent  discharge  shows 
that  the  further  plugging  is  unnecessary. 

The  removal  of  a  hematocele  by  the  abdominal  route  does  not 
call  for  any  special  description.  If,  on  opening  the  abdomen,  it 
is  found  that  infection  of  the  hematocele  has  occurred,  a  counter- 
opening  should  be  made  from  the  floor  of  Douglas's  pouch  into 
the  posterior  vaginal  fornix,  and  the  pelvis  drained  into  the  vagina 
by  means  of  gauze  plugging.  The  wound  in  the  abdominal  wall 
may  then  be  closed.  A  hematoma  of  the  broad  ligament  rarely 
calls  for  interference,  as,  if  left  alone,  it  will  be  almost  invariably 
absorbed  aseptically.  Should  suppuration  occur,  the  resultant 
abscess  must  be  opened  and  drained,  if  possible,  from  the  vagina. 

After  Rupture  of  the  Gestation  Sac — This  period  com- 
mences after  the  rupture  of  the  gestation   sac,  and  terminates 


THE  CLINICAL  ASPECT  OF  EXTRA-UTERINE  PREGNANCY     667 

with  the  removal  of  the  ovum,  whenever  that  may  occur.  For 
the  sake  of  convenience,  we  shall  also  discuss  here  the  treatment 
of  the  rare  cases  in  which  a  tubal  pregnancy  reaches  full  term 
without  causing  rupture  of  the  tube. 

Symptoms. — We  are  now  concerned  with  the  symptoms  of  extra- 
uterine pregnancy  during  the  last  half  of  pregnancy.  In  some  of 
these  cases  the  ovum  may  be  implanted  in  an  unruptured  tube, 
in  other  cases  in  an  unruptured  sac  formed  of  the  broad  ligament, 
and  in  a  third  class  of  cases  it  may  be  free  in  the  abdominal 
cavity.  In  the  first  class  of  cases,  no  rupture  of  the  gestation  sac 
has  occurred.  In  the  second  class,  the  tube  has  ruptured  into  the 
broad  ligament,  but,  inasmuch  as  the  pregnancy  has  continued, 
the  symptoms  of  rupture  may  have  been  so  slight  as  to  have 
escaped  notice.  In  the  third  class  of  cases,  the  tube  may  have 
ruptured  directly  into  the  peritoneal  cavity;  or,  it  may  have 
ruptured  first  into  the  broad  ligament,  and  the  secondary  gesta- 
tion sac  thus  formed  may  have  then  ruptured  into  the  peritoneal 
cavity.  In  these  cases,  also,  inasmuch  as  the  ovum  survived,  it 
is  probable  that  the  symptoms  of  rupture  were  so  slight  as  to 
have  escaped  notice. 

It  is  probable  that  the  presence  of  an  extra-uterine  pregnancy 
does  not  give  rise  to  any  special  symptoms  during  the  second 
half  of  pregnancy,  and  that  the  patient  may  arrive  at  full  term  quite 
unconscious  that  anything  is  the  matter.  Usually,  the  only 
special  symptom  to  which  the  condition  gives  rise  is  the  greater 
ease  with  which  the  movements  of  the  foetus  can  be  felt  by  the 
.patient,  and  the  pain  to  which  they  sometimes  give  rise.  When 
term  is  reached,  uterine  contractions  as  a  rule  ensue,  and  a  more 
or  less  complete  decidual  cast  of  the  uterus  may  be  expelled. 
Shortly  after  this,  the  patient  notices  a  cessation  in  the  fcetal 
movements,  due  to  the  death  of  the  foetus. 

The  physical  signs  of  an  extra-uterine  pregnancy  are  usually 
better  marked  than  are  the  symptoms,  but  it  is  quite  possible 
to  overlook  them  if  the  obstetrician  examines  the  case — as  is 
usually  done — without  any  thought  as  to  the  possibility  of  the 
presence  of  an  extra-uterine  pregnancy  in  his  mind.  The  first 
point  that  the  examiner  may  notice  is  the  ease  with  which  the 
fcetal  parts  are  felt  and  recognised,  and  the  distinctness  with 
which  the  foetal  movements  are  felt.  This  is  particularly  marked 
in  cases  in  which  the  foetus  is  free  in  the  abdominal  cavity  ;  if  it 
is  lying  in  an  extra-peritoneal  sac,  and  if  the  placenta  is  adherent 
to  the  anterior  abdominal  wall,  the  reverse  may  be  the  case. 
Next,  a  small  tumour  the  size  of  an  orange  may  be  found  pressed 
to  one  or  other  side  of  the  false  pelvis,  and  apparently  adherent 
to  the  sac  in  which  the  fcetus  is  contained.  This  tumour  is 
formed  by  the  empty  uterus.  In  some  cases,  however,  the  uterus 
may  be  displaced  backwards  or  downwards,  and  so  may  not  be 
palpable.  On  vaginal  examination,  prior  to  the  onset  of  spurious 
labour,  the  cervix  may  not  be  as  soft  as  is  usually  the  case  in 


668  THE  PATHOLOGY  OF  PREGNANCY 

pregnancy,  otherwise  there  will  be  little  to  direct  attention  to  the 
condition.  When  labour  has  apparently  commenced,  the  non- 
occurrence of  dilatation  of  the  cervix  and  of  descent  of  the  pre- 
senting part  may  in  some  cases  be  the  first  sign  to  draw  attention 
to  the  nature  of  the  case.  Then,  on  careful  bi-manual  examina- 
tion, it  may  be  possible  to  determine  the  connection  between  the 
laterally-placed  tumour  in  the  false  pelvis  and  the  cervix. 

After  the  death  of  the  foetus,  the  liquor  amnii  is  gradually 
absorbed  and  the  abdominal  enlargement  commences  to  grow 
smaller.  The  foetal  heart  can  be  no  longer  heard,  nor  the  foetal 
movements  felt.  Still  later  in  the  course  of  the  case,  as  one  or 
other  of  the  various  changes  that  have  been  already  described 
occur  in  the  foetus,  the  outlines  of  the  latter  become  indistinct, 
and,  instead  of  being  able  to  palpate  foetal  parts,  all  that  can  be 
felt  is  an  oval  tumour,  portions  of  which  are  more  resistant  than 
are  other  portions.  If  an  aseptic  change  in  the  foetus  takes  place, 
the  patient  may  carry  the  latter  for  years  without  suffering  very 
much,  save  from  pressure  symptoms  and  from  the  size  and  weight 
of  the  tumour.  If  suppuration  occurs  and  an  abscess  forms,  all 
the  symptoms  of  septic  absorption  will  be  present. 

Diagnosis. — The  diagnosis  of  extra-uterine  pregnancy  can,  as  a 
rule,  be  made  with  comparative  certainty  in  all  cases  in  which 
the  symptoms  are  sufficiently  marked  to  draw  the  attention  of 
the  patient  to  her  condition,  and  to  lead  her  medical  adviser  to 
examine  her  systematically.  In  many  instances,  however,  the 
patient  may  not  suspect  that  there  is  anything  abnormal  in  the  preg- 
nancy, and  it  may  be  that  the  condition  is  only  recognised,  during 
the  course  of  spurious  labour,  on  account  of  the  non-descent  of 
the  presenting  part.  Further,  in  still  other  cases,  the  symptoms 
of  spurious  labour  may  be  so  slight  that  they  come  and  go  un- 
noticed, and  then  attention  may  only  be  drawn  to  the  condition 
by  the  gradual  shrinkage  of  the  abdominal  tumour,  and  by  the 
fact  that  the  date  fixed  for  the  confinement  is  past. 

There  are  two  steps  in  the  diagnosis  of  extra-uterine  pregnancy 
during  this  period.  The  first  step  consists  in  determining  the 
existence  of  pregnancy,  the  second  step  in  determining  that  the 
pregnancy  is  extra-uterine. 

The  diagnosis  of  pregnancy  is  a  comparatively  simple  matter. 
At  the  period  with  which  we  are  now  dealing,  it  will  be  possible 
to  obtain  the  positive  signs  of  pregnancy,  i.e.,  the  foetal  heart,  the 
foetal  parts,  and  the  foetal  movements.  In  cases  in  which  the 
foetus  is  dead,  it  will,  of  course,  be  impossible  to  obtain  the  first 
and  the  last  sign,  and  if  death  occurred  many  weeks  prior  to  the 
examination  of  the  patient,  it  may  be  also  impossible  to  palpate 
the  foetal  limbs  on  account  of  the  post-mortem  changes  which 
have  taken  place  in  their  tissues.  In  such  cases,  we  must  rely  on 
the  history  of  the  patient,  supported  as  it  will  be  by  the  presence 
of  an  abdominal  tumour. 

The  determination  that  the  pregnancy  is  extra-uterine  is  a  more 


THE  CLINICAL  ASPECT  OF  EXTRA-UTERINE  PREGNANCY    669 

difficult  matter,  and  even  if  a  careful  bi-manual  examination  is 
made,  the  difficulty  of  diagnosing  the  condition  is  often  very  great. 
This  difficulty  in  the  main  arises  from  the  actual  or  apparent  close 
connection  between  the  gestation  sac  and  the  uterus.  Practically, 
we  may  consider  that  the  gestation  sac  is  found  in  three  relations 
to  the  uterus.  First,  it  may  be  quite  distinct  and  easily  separated 
from  the  latter.  This  is  the  usual  relation  in  cases  of  secondary 
abdominal  pregnancy  during  the  first  half  of  the  period  with 
which  we  are  dealing,  that  is  to  say,  before  the  ovum  has  filled 
the  abdominal  cavity.  Secondly,  it  may  be  actually  attached  to 
one  or  other  side  of  the  uterus.  This  again  is  the  usual  rela- 
tion in  cases  of  unruptured  broad-ligamentous  pregnancy,  or  of 
interstitial  pregnancy.  Thirdly,  it  may  be  apparently  attached 
to  the  uterus  in  consequence  of  its  being  pressed  against  it  by 
the  pressure  of  the  abdominal  walls.  This  will  naturally  happen, 
as  soon  as  the  ovum  has  reached  such  a  size  that  it  fills  the  entire 
abdomen. 

When  we  are  able  to  determine  the  presence  of  a  tumour 
distinct  from  the  uterus,  and  inside  which  there  is  a  foetus,  the 
diagnosis  is  made.  The  only  point  in  such  cases  is  to  eliminate 
the  possibility  of  a  co-existent  intra-uterine  pregnancy.  This  can 
be  done  in  the  usual  manner  by  noting  the  size  of  the  uterus. 

In  the  second  and  third  class  of  case,  we  find  a  gestation  sac 
occupying  the  abdomen,  and  to  one  or  other  side  of  it  is  affixed 
a  small  mass  of  firmer  consistency  than  the  sac  itself.  Such  a 
condition  may  be  due  to  several  different  causes.  In  the  first 
place,  and  perhaps  most  commonly,  the  gestation  sac  may  be 
formed  in  the  usual  manner  by  the  enlarged  uterus,  and  the 
smaller  tumour  to  the  side  may  be  a  myoma.  Next,  the  smaller 
tumour  may  be  the  uterus,  and  the  gestation  sac  may  be  formed 
by  the  broad  ligament,  or  the  ovum  may  be  free  in  the  abdominal 
cavity  and  only  in  apparent  connection  with  the  uterus.  And, 
lastly,  the  gestation  sac  may  be  formed  of  one  horn  of  a  bi- 
cornuate  uterus  or  one  half  of  a  double  uterus,  the  smaller 
tumour  being  formed  by  the  other  cornu  or  half  of  the  uterus  as 
the  case  may  be.  In  uterine  pregnancy,  complicated  by  a  myoma, 
there  is  nothing  in  the  history  or  the  symptoms  of  the  patient  to 
suggest  extra-uterine  pregnancy.  The  painless  contractions  of 
the  uterus  are  felt  in  the  ordinary  manner,  and  the  softening  of 
the  cervix  and  lower  uterine  segment,  and  the  other  objective 
uterine  symptoms  of  pregnancy,  are  present.  The  greater  the 
amount  of  liquor  amnii,  or,  in  other  words,  the  greater  the  size  of 
the  gestation  sac,  the  greater  will  be  the  difficulty  of  diagnosis, 
as  the  small  empty  uterus  may  be  so  completely  hidden  by  the 
larger  tumour  that  it  is  impossible  to  recognise  its  presence.  In 
such  cases,  the  only  course  to  adopt  is  to  wait  until  it  is  obvious 
that  term  has  passed,  as  shown  by  the  death  of  the  foetus  and 
the  commencing  diminution  in  size  of  the  gestation  sac.  If  term 
is  passed  and  the  foetus  is  dead,  the  passage  of  the  sound  will 


670  THE  PATHOLOGY  OF  PREGNANCY 

furnish  positive  evidence.  If  the  smaller  tumour  is  the  uterus,  the 
sound  will  pass  into  it ;  if  the  larger  tumour  is  the  uterus,  the 
sound  will  pass  into  it. 

If  the  smaller  tumour  is  a  non-impregnated  uterus,  and  the 
gestation  sac  is  between  the  layers  of  the  broad  ligament  or  free 
in  the  abdominal  cavity,  it  may  be  possible  on  careful  examina- 
tion to  determine  that  the  cervix  is  continuous  with  the  smaller 
tumour.  Also,  the  objective  uterine  signs  of  pregnancy  will  not 
be  so  marked  as  if  the  pregnancy  was  intra-uterine.  If  it  is 
allowable  to  pass  the  sound,  it  will  again  make  the  diagnosis 
obvious.  Pregnancy  occurring  in  one  half  of  a  double  uterus 
will,  according  to  Taylor,*  only  confuse  those  who  have  no  know- 
ledge of  the  condition.  The  presence  of  a  double  cervix  can  be 
determined  by  vaginal  examination,  or  by  inspection  through  a 
speculum.  Where  pregnancy  occurs  in  one  horn  of  a  two-horned 
uterus,  the  non-impregnated  horn  forming  the  smaller  tumour, 
the  diagnosis  is  very  much  more  difficult.  It  is  probable  that 
such  cases  will  be  mistaken  for  the  more  common  condition  to 
which  we  have  already  referred,  i.e.,  a  uterine  pregnancy  compli- 
cated by  a  small  myoma  at  one  or  other  side.  Usually,  labour 
will  proceed  in  the  ordinary  manner  and  the  foetus  be  expelled. 
Where  there  is  no  connection  between  the  pregnant  horn  and  the 
cervix,  the  nature  of  the  case  will  only  be  determined  during 
labour,  in  consequence  of  the  non-dilatation  of  the  uterine  orifice. 
Such  a  case  is,  to  all  intents  and  purposes,  a  case  of  extra-uterine 
pregnancy. 

It  is  probable  that,  in  some  cases,  a  diagnosis  will  only  be  made 
by  waiting  until  the  onset  of  spurious  labour  and  the  death  of 
the  foetus  have  made  it  permissible  to  introduce  the  sound.  If  the 
latter  passes  into  the  gestation  sac,  we  know  that  we  are  dealing 
with  a  case  of  missed  labour.  If,  on  the  other  hand,  it  passes 
into  a  smaller  cavity  at  the  side  of  the  gestation  sac,  we  know 
that  we  are  dealing  with  some  form  of  extra-uterine  pregnancy, 
or  with  a  pregnancy  contained  in  a  uterine  cornu,  which  is  not  in 
communication  with  the  cervix. 

Treatment. — The  treatment  of  extra-uterine  pregnancy  during 
this  stage  is  as  yet  far  from  being  clearly  laid  down.  The  ideal 
line  of  treatment  consists  in  waiting  until  full  term,  then  opening 
the  abdomen  and  removing  a  living  foetus  and  the  gestation  sac 
and  placenta.  This  procedure  is,  however,  a  most  difficult  and 
dangerous  one,  as  at  term  the  placental  vessels  have  reached  their 
full  size,  and  the  difficulty  of  removing  the  placenta  without  at 
the  same  time  causing  haemorrhage  which  cannot  be  checked,  is 
very  considerable.  At  an  earlier  period  in  pregnancy,  the  vessels 
are  smaller  than  at  term,  and  some  weeks  after  term  they  are  also 
smaller  on  account  of  the  shrinkage  of  the  placenta  consequent 
on  the  death  of  the  foetus.  Accordingly,  we  must  at  present 
consider  that  though  an  operation  at  term  offers  the  most  favour- 

*  Ob.  cit. 


THE  CLINICAL  ASPECT  OF  EXTRA-UTERINE  PREGNANCY     671 

able  prospect  for  the  fcetus,  it  offers  the  most  unfavourable 
prospect  for  the  mother,  and  must  therefore,  in  most  cases,  be 
rejected. 

It  is  by  no  means  easy  to  lay  down  definitely  what  is  the  best 
time  at  which  to  operate  in  a  case  in  which  the  existence  of  an 
extra-uterine  pregnancy  is  recognised  as  early  as  the  fifth  month. 
Several  points  have  to  be  taken  into  consideration.  It  is  im- 
possible in  most  cases  to  tell,  without  opening  the  abdomen,  the 
exact  position  of  the  ovum,  and,  consequently,  it  is  impossible  to 
be  sure  that  secondary  rupture  of  the  sac  may  not  occur  at  any 
moment.  Accordingly,  the  dread  of  secondary  rupture  makes  us 
inclined  to  operate  at  once.  On  the  other  hand,  according  to 
Pinard,:;:  the  danger  of  operating  during  or  after  the  fifth  month 
differs  but  little  from  the  danger  at  term,  so  far  as  haemorrhage 
from  the  placental  site  is  concerned,  as  by  this  time  the  placenta 
is  of  considerable  size.  A  third  course  must  also  be  taken  into 
consideration.  If  the  removal  of  the  foetus  is  postponed  until 
some  weeks  after  full  term,  the  placenta  will  by  that  time 
have  shrunk  and  its  vessels  become  smaller.  Consequently,  the 
danger  of  haemorrhage  during  the  removal  of  the  placenta  is 
not  so  great.  This  course,  however,  means  the  certain  loss  of 
the  foetus,  and  there  is  also  some  risk  that  putrefactive  changes 
may  take  place  in  the  ovum. 

We  may  then,  perhaps,  consider  that,  if  the  physical  signs  lead 
us  co  believe  that  the  fcetus  is  free  in  the  abdominal  cavity,  and 
that,  consequently,  there  is  no  danger  of  secondary  rupture,  the 
operation  may  be  postponed  until  at  or  after  full  term.  If  the 
special  circumstances  of  the  case  make  it  necessary  to  run  any 
risk  in  order  to  save  the  foetus,  operation  may  be  undertaken  at 
term,  If,  on  the  other  hand,  it  is  considered  advisable  to  consult 
the  interests  of  the  mother  alone,  operation  had  better  be  post- 
poned until  several  weeks  after  term.  If  the  examination  of  the 
patient  goes  to  show  that  the  foetus  is  probably  lying  in  the  broad 
ligament,  it  is  probably  best  to  operate  on  the  case  as  soon  as  it 
is  diagnosed,  unless  the  condition  is  not  recognised  until  near  full 
term,  when  the  foetus  has  reached  its  full  size  and  the  risk  of 
secondary  rupture  may  be  ignored. 

The  operation  for  the  removal  of  an  extra-uterine  pregnancy 
in  which  there  is  a  fully-developed  placenta  is  most  difficult,  on 
account  of  the  presence  of  the  placental  vessels.  There  are  four 
courses,  one  of  which  it  may  be  possible  to  adopt : — 

(1)  After  the  removal  of  the  foetus,  the  sac  and  placenta  may 
be  extirpated,  the  vascular  attachments  of  the  latter  being 
gradually  separated  after  ligation  of  the  vessels.  This  is  the 
ideal  course,  and  it  can  usually  be  carried  out  in  all  cases  in 
which  the  operation  has  been  postponed  for  some  weeks  after 
term,  as  by  that  time  the  vessels  going  to  the  placenta  have  in 
great  part  become  obliterated. 

*  Bull,  de  V Academic  dc  Medecine,  August  6,  1895. 


672  THE  PATHOLOGY  OF  PREGNANCY 

(2)  If  there  is  a  distinct  sac  in  which  the  foetus  is  contained, 
after  the  removal  of  the  latter  the  edges  of  the  sac  are  stitched 
to  the  opening  of  the  abdominal  wall,  the  cord  is  brought  out 
through  the  same  opening,  and  the  sac  is  plugged  with  iodoform 
gauze.  This  gauze  may  be  left  in  situ  for  two  or  three  days,  or  if. 
there  is  any  elevation  of  temperature,  it  may  be  changed  daily. 
At  the  end  of  fifteen  to  twenty  days  the  patient  is  again  anaes- 
thetised and  the  placenta  removed,  any  haemorrhage  being  checked 
either  by  ligation  of  a  bleeding  vessel  or  by  plugging  the  sac 
with  gauze.  If  the  removal  of  the  entire  placenta  is  effected, 
the  abdominal  wound  may  be  closed  by  sutures,  or,  if  considered 
necessary,  the  cavity  may  be  drained  until  it  becomes  obliterated. 
This  is  probably  the  best  course  to  adopt  in  cases  which  are 
operated  upon  during  the  life  of  the  foetus. 

(3)  The  third  procedure  consists  in  cutting  the  umbilical  cord 
close  to  its  insertion,  and  allowing  the  placenta  to  remain  per- 
manently in  position,  the  abdominal  wound  being  closed.  Cases 
have  been  recorded  in  which  this  procedure  has  been  adopted 
with  success.  It  is,  however,  by  no  means  free  from  risk,  on 
account  of  the  danger  of  infection  of  the  placenta  from  the  intes- 
tines, and  is  at  best  a  dernier  ressort. 

In  the  majority  of  cases,  it  is  advisable  to  commence  the  initial 
incision  in  the  abdominal  wall  midway  between  the  umbilicus  and 
the  symphysis.  If  the  foetus  is  lying  in  an  extra-peritoneal  sac, 
it  is  always  well  to  endeavour  to  open  directly  into  the  sac  with- 
out opening  into  the  peritoneal  cavity,  and,  consequently,  the 
incision  should  be  as  near  to  the  symphysis  as  is  possible  without 
wounding  the  bladder.  If  it  is  clear  that  the  sac  is  situated  to  one 
or  other  side,  a  lateral  incision  over  Poupart's  ligament  may  take 
the  place  of  a  median  one,  but,  usually,  it  will  be  found  best  to 
make  the  median  opening  first,  and  then,  if  it  is  found  that  an 
opening  in  a  different  place  will  enable  us  to  reach  the  ovum  more 
advantageously,  such  opening  may  be  made  and  the  initial  incision 
closed. 


CHAPTER  IX 
ANTEPARTUM  HEMORRHAGES 

Haemorrhages  occurring  during  the  First  Three  Months — Differential  Diag- 
nosis. Haemorrhages  occurring  during  the  Second  Three  Months — Due 
to  Detachment  of  the  Placenta.  Haemorrhage  occurring  during  the 
Last  Four  Months  —  Accidental  Haemorrhage;  Concealed;  External — 
Unavoidable  Haemorrhage  —  Foetal  Mortality  in  Accidental  and  Un- 
avoidable Haemorrhage — Haemorrhage  due  to  Rupture  of  the  Uterus. 
Haemorrhage  arising  independently  of  the  Pregnancy — The  Question 
of  Menstruation  during  Pregnancy  —  Haemorrhage  from  Tumours  — 
Haemorrhage  from  Traumatisms. 

Antepartum  haemorrhages  arising  as  a  direct  result  of  the  preg- 
nancy may  be  divided  into  three  main  groups  : — 

A.  Haemorrhages  occurring  during  the  first  three  months  of 
pregnancy. 

B.  Haemorrhages  occurring  during  the  second  three  months  of 
pregnancy. 

C.  Haemorrhages  occurring  during  the  last  four  months. 

In  adopting  this  classification,  the  duration  of  pregnancy  is 
considered  as  ten  lunar  months  of  four  weeks  each.  The  first 
group  includes  haemorrhages  occurring  before  the  full  formation 
of  the  placenta.  The  second  group  includes  haemorrhages  occur- 
ring from  the  time  the  placenta  is  formed  to  the  time  the  foetus 
becomes  viable.  The  last  group  includes  haemorrhages  occurring 
after  the  foetus  is  viable. 


HEMORRHAGES  OCCURRING  DURING  THE  FIRST 
THREE  MONTHS 

The  haemorrhages  of  the  first  three  months  of  pregnancy,  which 
arise  as  a  direct  result  of  the  pregnancy,  have  three  chief 
causes  : — abortion  ;  extra-uterine  pregnancy  ;  and  vesicular  mole. 

Inasmuch  as  each  of  these  conditions  has  been  already  fully 
discussed,  we  shall  here  confine  ourselves  to  a  brief  account  of  the 
methods  of  distinguishing  between  them. 

In  order  to  recognise  the  cause  of  haemorrhage  in  any  case,  the 
following  points  must  be  ascertained  : — 

673  43 


674  THE  PATHOLOGY  OF  PREGNANCY 

(i)  The  existence  of  pregnancy. 

(2)  The  duration  of  pregnancy. 

(3)  The  present  size  of  the  uterus,  and  the  nature  of  any 

alterations  which  may  take  place  in  it  from  day  to 
day.  • 

(4)  The  condition  of  the  adnexa. 

(5)  The  nature  and  duration  of  the  discharge. 

(6)  The  nature  of  any  solid  matter  which  may  have  been 

expelled  from  the  uterus. 

(7)  The  condition  of  the  cervix. 

(8)  The  symptoms  of  the  patient. 

The  Existence  of  Pregnancy. — The  existence  of  pregnancy  is 
the  first  point  to  be  decided.  This  can  be  done  by  determining 
the  presence  of  its  usual  subjective  and  objective  symptoms. 

The  Duration  of  Pregnancy. — The  duration  of  pregnancy  must 
be  ascertained  as  far  as  possible  by  the  patient's  history,  with- 
out taking  the  size  of  the  uterus  into  consideration.  This  is 
an  important  point  to  remember,  as  in  some  cases  the  diagnosis 
of  the  nature  of  the  case  will  be  largely  based  upon  the  difference 
between  the  actual  size  of  the  uterus  and  the  size  it  ought  to  be 
in  accordance  with  the  period  of  pregnancy. 

The  Present  Size  of  the  Uterus,  and  the  Nature  of  the  Altera- 
tions which  take  place  in  it  from  Day  to  Day. — The  present  size 
of  the  uterus  is  a  considerable  aid  to  diagnosis  in  cases  of  haemor- 
rhage, when  it  is  taken  in  connection  with  the  supposed  date  of 
pregnancy.  If  the  uterus  corresponds  in  size  with  the  duration 
of  pregnancy,  it  is  strong  evidence  for  supposing  that  it  contains 
a  living  ovum,  or  one  which  has  only  quite  recently  died.  If, 
however,  the  uterus  is  larger  than  the  period  of  pregnancy 
accounts  for,  the  possibility  of  vesicular  mole  must  be  remembered. 
If,  again,  the  uterus  is  smaller  than  the  period  of  pregnancy 
would  lead  us  to  suppose  it  ought  to  be,  it  suggests,  first,  that 
perhaps  the  pregnancy  is  extra-uterine,  and,  secondly,  if  that 
supposition  is  proved  to  be  erroneous,  that  the  ovum  is  probably 
dead. 

The  alteration  in  size  of  the  uterus  from  day  to  day  is  also 
important.  If  it  increases  at  the  natural  rate,  it  is  almost  con- 
clusive evidence  that  the  ovum  is  intra-uterine  and  living.  The 
only  other  condition  under  which  this  rate  of  increase  could  occur 
is  in  the  case  of  a  missed  abortion,  in  which  just  sufficient  intra- 
uterine haemorrhage  is  taking  place  each  day  to  cause  the  same 
rate  of  increase  that  a  growing  ovum  would  cause.  Such  a 
state  of  affairs  is  necessarily  so  rare  that  in  practice  it  may  be 
neglected.  If  the  uterus  ceases  to  increase  in  size,  or  even  com- 
mences to  become  smaller,  it  is  equally  strong  evidence  that  the 
ovum  is  dead,  that  is,  that  a  condition  of  missed  abortion  is 
present.  If  the  uterus  grows  more  rapidly  than  is  normal,  it  is 
strongly  suggestive  of  vesicular  mole. 

The  Condition  of  the  Adnexa. — The  condition  of  the  adnexa  is 


THE  DIAGNOSIS  OF  EARLY  UTERINE  HEMORRHAGE       675 

of  importance,  if  the  question  of  the  possibility  of  the  existence 
of  an  extra-uterine  pregnancy  arises.  If  the  adnexa  are  normal 
on  both  sides,  the  possibility  of  extra-uterine  pregnancy  is 
immediately  eliminated.  The  typical  condition  met  with  in  extra- 
uterine pregnancy  prior  to  the  rupture  of  the  sac  is  as  follows  : — 
A  globular  or  ovoid  tumour,  varying  in  size  from  a  pullet's  egg 
to  an  orange,  is  found  at  one  or  other  side,  corresponding  in 
position  to  the  tube  of  the  same  side.  The  tumour  is  elastic  to 
the  touch,  and  slight  pulsation  may  be  felt  in  it  owing  to  the  in- 
creased size  of  the  vessels  which  supply  it.  The  uterus,  which 
is  also  somewhat  enlarged,  is  displaced  towards  the  opposite  side 
by  the  tumour.  If  rupture  has  occurred,  it  may  be  possible  to 
determine  the  disappearance  of  a  tumour  whose  existence  had 
been  previously  ascertained,  and  the  gradual  formation  of  another 
tumour  in  Douglas's  pouch. 

The  physical  signs  which  help  to  distinguish  between  an  un- 
ruptured tubal  pregnancy  and  any  other  tumour  of  the  adnexa 
are : — 

(1)  In  tubal  pregnancy  the  enlargement  corresponds  to  the 
position  of  a  tube  rather  than  of  an  ovary.  Ovarian  pregnancy 
is  said  to  occur,  but  it  is  so  rare  that  it  may  be  neglected. 

(2)  An  extra-uterine  pregnancy  is  usually  unilateral.  Inflam- 
matory disease  of  the  tubes  is  almost  always  bilateral. 

(3)  The  sac  of  a  pregnancy  pulsates,  and  occasionally  contrac- 
tions of  its  walls  may  be  felt  (Kelly). 

The  Nature  and  Duration  of  the  Discharge. — Slight  hemorrhagic 
discharge  is  not  indicative  of  anything  definite.  It  occurs  in  all 
forms  of  abortion,  in  extra-uterine  pregnancy,  and  in  vesicular 
mole.  Profuse  haemorrhage  is  conclusive  evidence  of  some  form 
of  abortion,  most  probably  threatened  or  incomplete.  A  profuse, 
watery,  blood-stained  discharge  points  strongly  to  vesicular  mole. 
If  small  cysts  are  found  in  it,  it  is  pathognomonic  of  that  con- 
dition. More  or  less  profuse  dark-coloured  discharge  shows  that 
the  ovum  is  dead,  and  that  part  or  all  of  it  is  still  retained  in  the 
uterus.  Putrid  discharge  shows  that  the  ovum  is  not  only  dead, 
but  that  decomposition  has  occurred.  If  the  discharge  quickly 
lessens,  and  after  a  few  days  disappears  altogether,  it  may  usually 
be  taken  to  show  either  that  the  danger  of  the  expulsion  of  the 
ovum  has  passed  off,  or  that  the  uterus  has  emptied  itself — that  is, 
that  complete  abortion  has  occurred. 

The  Nature  of  any  Solid  Matter  which  may  have  been  expelled 
from  the  Uterus. — It  cannot  be  too  strongly  insisted  upon  that, 
in  the  case  of  a  patient  who  is  bleeding,  all  matter  which  is  ex- 
pelled from  the  uterus  must  be  most  carefully  examined.  It  is 
by  so  doing  that,  in  the  majority  of  cases,  we  obtain  the  necessary 
information  to  enable  a  diagnosis  to  be  made.  The  expelled 
matter,  if  we  can  obtain  it  all,  gives  absolute  information  as  to 
what  has  happened  in  the  uterus,  while  the  information  obtained 
in  other   ways  is  generally   more  or  less  problematical.     If  an 

43—2 


676  THE  PATHOLOGY  OF  PREGNANCY 

entire  ovum  is  expelled,  it  is  self-evident  that  complete  abortion 
has  taken  place,  or,  if  only  a  portion,  that  the  abortion  is  incom- 
plete. In  order  to  be  absolutely  certain  that  the  case  is  one  of 
abortion,  either  chorionic  villi  or  some  fragment  of  a  foetus  must 
be  found.  A  mere  mass  of  decidua  does  not  enable  us  at  first 
sight  to  say  whether  the  case  is  one  of  intra-  or  extra-uterine 
pregnancy  ;  a  microscopical  examination  of  it  will  be  necessary. 
Dakin  states  that  the  true  decidua  of  an  intra-uterine  pregnancy 
is  indistinguishable  from  the  false  decidua  of  extra-uterine  preg- 
nancy. However,  in  the  former  case,  some  fragment  of  chorion 
or  amnion  will  be  found  by  the  aid  of  the  microscope,  and  this, 
of  course,  is  pathognomonic.  If  intra-uterine  pregnancy  is  ex- 
cluded, the  expulsion  of  a  decidual  cast  of  the  uterus,  in  associa- 
tion with  a  growing  pelvic  tumour,  is  diagnostic  of  an  extra- 
uterine pregnancy  (Routh).  As  has  been  mentioned  above, 
the  presence  of  cysts  in  the  discharge  is  pathognomonic  of 
vesicular  mole. 

The  Condition  of  the  Cervix. — The  condition  of  the  cervix  is  of 
assistance,  not  only  in  determining  whether  the  patient  is  pregnant 
or  not,  but  also  in  distinguishing  between  the  different  forms  of 
abortion.  In  a  threatened  abortion,  the  cervical  canal  usually 
becomes  slightly  patulous.  If  the  ovum  has  been  detached  and 
is  in  process  of  expulsion,  it  is  forced  against  the  inner  os,  which 
accordingly  dilates,  the  external  os  still  remaining  closed.  The 
cervix  as  a  result  becomes  conical  in  shape,  the  base  of  the  cone 
corresponding  with  the  cervico-vaginal  junction,  the  apex  with 
the  external  os  (v.  Fig.  295  a)  ;  in  other  words,  the  circumference 
of  the  cervix  at  the  cervico-vaginal  junction  is  increased.  If  the 
external  os  will  not  dilate  to  allow  the  ovum  to  pass  through,  the 
latter  is  gradually  expelled  into  the  cervical  canal,  which  dilates 
to  a  sufficiently  large  size  to  receive  it.  The  inner  os  may  then 
partially  contract  again,  and  the  ovum  become  incarcerated  in 
the  ballooned-out  cervical  canal.  Thus,  the  condition  known  as 
cervical  abortion  arises.  If,  however,  the  external  os  dilates  in 
the  usual  manner  and  the  ovum  is  expelled,  the  inner  os  closes 
again  completely,  while  the  external  os  remains  dilated  for  some 
days.  The  cervix  thus  acquires  a  trumpet-shape,  the  mouth  of 
the  trumpet  corresponding  to  the  external  os  (Fig.  295  b).  If 
the  ovum  has  been  completely  expelled,  the  cervix  gradually 
regains  its  normal  shape  ;  if,  on  the  contrary,  a  part  of  the  ovum 
is  retained,  complete  closure  of  the  canal  rarely  occurs. 

The  Symptoms  of  the  Patient. — The  three  chief  symptoms  of 
the  patient  in  either  abortion  or  extra-uterine  pregnancy  are 
haemorrhage,  pain,  and  collapse.  In  abortion,  the  three  have 
usually  a  due  relationship  to  one  another,  and  the  degree  of 
collapse  is  in  proportion  to  the  amount  of  haemorrhage  and  pain 
which  is  occurring.  The  amount  of  pain  is,  however,  by  no 
means  constant.  In  the  case  of  a  ruptured  extra-uterine  preg- 
nancy, on  the  other  hand,  the  first  point  which  may  strike  us 


THE  DIAGNOSIS  OF  EARLY  UTERINE  HEMORRHAGE       677 

with  regard  to  the  case  is  that  the  collapse  is  altogether  out  of 
proportion  to  the  amount  of  haemorrhage  which  is  apparently 
occurring.  The  accompanying  pain  is  also  greater  than  in 
abortion.  Such  a  condition  should  always  very  forcibly  suggest 
the  possibility  of  internal  haemorrhage.  In  missed  abortion,  the 
previously  existing  subjective  symptoms  of  pregnancy  disappear, 
and  are  replaced  by  various  ill-defined  phenomena,  the  result  of 
the  absorption  of  ptomaines  from  the  dead  ovum. 

The  foregoing  are  the  principal  diagnostic  phenomena  to  be 
looked  for  in  any  case  of  haemorrhage  during  the  first  three  months 
of  pregnancy,  and  it  may  be  of  use  to  sum  them  up  in  their 
relationship  to  the  various  causes  of  haemorrhage. 

A  uterus  corresponding  in  size  to  the  period  of  pregnancy  ;  a 


Fig.  295. — Diagram  showing  the  Shape  of  the  Cervix  during   and 
subsequent  to  the  expulsion  of  the  ovum. 

UC,  Uterine  cavity  ;    OI,  os  internum  :  OE,  os  externum  ;  V,  vagina. 


varying  amount  of  haemorrhage  and  pain,  with  a  corresponding 
degree  of  collapse  ;  widening  of  the  cervix  at  the  cervico-vaginal 
junction  ;  and  a  slightly  patulous  condition  of  the  external  os,  are 
suggestive  of  threatened  abortion. 

Marked  ballooning  of  the  cervical  canal ;  closure  of  the  os 
externum,  which  has  a  thin  parchment-like  edge  ;  and  a  varying 
amount  of  dark,  perhaps  putrid,  discharge,  are  indicative  of 
cervical  abortion. 

The  expulsion  of  a  portion  of  the  ovum  ;  slight  diminution  in 
size  of  the  uterus  ;  a  patulous  cervical  canal ;  and  a  profuse  dark 
discharge,  or  even  a  sharp  haemorrhage,  are  indicative  of  incom- 
plete abortion. 


6; 8  THE  PATHOLOGY  OF  PREGNANCY 

The  expulsion  of  the  entire  ovum  ;  a  trumpet-shaped  condition 
of  the  cervix  ;  a  marked  diminution  in  the  size  of  the  uterus  ;  and 
the  gradual  diminution  and  final  disappearance  of  all  discharge, 
are  indicative  of  complete  abortion. 

A  cessation  of  development,  or  a  gradual  diminution  in  size  of 
the  uterus  ;  a  dark  hemorrhagic  discharge,  which  may  be  foetid  ; 
disappearance  of  the  subjective  and  objective  symptoms  of 
pregnancy,  and  general  ill-health  on  the  part  of  the  patient,  are 
suggestive  of  missed  abortion. 

The  existence  of  an  ovoid  and  pulsating  tumour  at  one  side  of  the 
uterus ;  a  history  of  pregnancy  ;  an  enlarged  uterus,  correspond- 
ing in  size  to,  or  slightly  smaller  than,  the  date  of  pregnancy 
accounts  for ;  slight  irregular  haemorrhages  ;  and  perhaps  the 
expulsion  of  a  decidua  in  which  no  trace  of  chorionic  villi  or 
amnion  can  be  found,  are  suggestive  of  an  unruptured  extra- 
uterine pregnancy. 

A  varying  degree  of  haemorrhage ;  the  expulsion  of  a  decidua 
m  which  no  trace  of  chorion  or  amnion  can  be  found ;  con- 
siderable pain ;  collapse  out  of  proportion  to  the  amount  of 
external  haemorrhage ;  and  perhaps  the  disappearance  of  a 
previously-discovered  pelvic  tumour,  with  the  formation  of  a  new 
tumour  in  Douglas's  pouch,  are  suggestive  of  a  ruptured  extra- 
uterine pregnancy. 

Marked  increase  in  size  of  the  uterus,  out  of  proportion  to  the 
period  of  pregnancy  ;  a  profuse  watery  blood-stained  discharge, 
perhaps  containing  cysts ;  and  crampy  pains,  are  indicative  of 
vesicular  mole. 


HAEMORRHAGES    OCCURRING    DURING    THE 
SECOND  THREE  MONTHS 

Three  varieties  of  haemorrhage  are  met  with  during  the  second 
three  months  of  pregnancy  : — 

I.   Haemorrhage  due  to  detachment  of  the  placenta. 
II.  Haemorrhage  due  to  extra-uterine  pregnancy. 
III.   Haemorrhage  due  to  degeneration  of  the  ovum. 
Haemorrhage  due  to  the  last  two  causes  has  been  already  dis- 
cussed, and  consequently  we  are  alone  concerned  with   haemor- 
rhage due  to  the  detachment  of  the  placenta. 

HEMORRHAGE    DUE    TO    DETACHMENT    OF    THE    PLACENTA. 

Haemorrhages  occurring  during  the  second  three  months  of 
pregnancy  due  to  detachment  of  the  placenta,  occupy  an  inter- 
mediate, position  between  abortion  and  accidental  or  unavoidable 
haemorrhages. 

With  the  exception  of  a  small  proportion  of  cases  which  are 
due  to  degeneration  of  the  ovum,  we  find  that,  while  aetiologically 


HEMORRHAGES  OF  THE  SECOND  THREE  MONTHS         679 

these  haemorrhages  can  be  classified  in  the  same  manner  as  can 
the  haemorrhages  of  the  last  four  months,  clinically  they  must 
be  treated  as  are  those  of  the  first  three.  The  reason  of  this  is 
obvious.  In  the  four  last  months  of  pregnancy,  it  is  always 
possible  to  distinguish  clinically  between  the  two  great  classes  of 
haemorrhage — i.e.,  haemorrhage  coming  from  a  normally  situated 
placenta,  and  haemorrhage  coming  from  a  placenta  prsevia  ;  in 
the  second  three  months  of  pregnancy,  it  is  not  possible  to  do  so, 
although  the  two  classes  occur.  Consequently,  while  in  the  four 
last  months,  we  can  diagnose  exactly  the  nature  of  the  case,  and 
treat  it  accordingly  in  the  most  suitable  manner,  in  the  second 
three  months  all  we  can  do  is  to  recognise  that  the  patient  is 
bleeding,  and  that  the  haemorrhage  is  either  so  trifling  as  only  to 
require  palliative  treatment,  or  so  serious  as  to  demand  more 
radical  measures. 

Aetiology. — As  has  been  pointed  out  above,  the  haemorrhage 
may  come  from  a  placenta  which  is  normal  in  position,  or  from 
one  which  is  praevia.  The  distinction  between  the  two,  which 
cannot  be  made  prior  to  the  expulsion  of  the  ovum,  can  in  most 
cases  be  made  subsequent  to  that  event.  This  is  done  by  noting 
the  relationship  of  the  opening  in  the  membranes,  through  which 
the  foetus  was  expelled,  to  the  placenta,  if  there  is  such  an  opening. 
If  the  opening  is  quite  close  to  the  placenta,  or  even  through  the 
latter,  it  shows  that  the  placenta  must  have  been  implanted  quite 
close  to,  or  right  over,  the  os.  In  some  of  these  cases,  however, 
the  ovum  when  expelled  spontaneously  is  unruptured  ;  while,  in 
those  cases  in  which  it  has  to  be  removed,  the  membranes  become 
so  torn  that  it  is  impossible  to  determine  the  above  relationship. 
Even  in  the  cases  in  which  the  placenta  is  certainly  praevia,  it  is 
doubtful  whether  its  situation  is  the  cause  of  its  detachment,  or 
whether,  rather,  the  latter  is  not  really  due  to  such  similar  causes 
as  act  in  the  case  of  a  normally  seated  placenta,  the  fact  that 
the  placenta  is  praevia  being  a  chance  accompaniment.  The 
causes  of  the  detachment  of  a  normally  situated  placenta  are  to 
be  found  in  some  diseased  condition  of  itself  or  of  the  decidua 
serotina,  and  are  as  follows: — Decidual  endometritis;  marked 
infarction  of  the  placenta ;  syphilis,  affecting  either  the  placenta 
or  decidua  ;  and,  perhaps,  the  situation  of  the  whole  or  part  of  the 
placenta  in  the  lower  uterine  segment. 

Symptoms. — The  essential  symptom  of  these  cases  is  the  occur- 
rence of  haemorrhage,  perhaps  accompanied  by  the  death  of  the 
foetus.  In  the  large  majority  of  cases,  the  haemorrhage  is 
external — i.e.,  it  escapes  from  the  uterine  cavity  as  rapidly  as  it 
finds  its- way  into  the  latter  from  the  bloodvessels.  In  a  smaller 
proportion  of  cases,  on  the  other  hand,  it  may  remain  stored  in 
the  uterus,  which  gradually  increases  in  size  to  suit  the  demands 
of  the  accumulating  blood.  If  the  area  of  placental  detachment 
is  so  great  as  to  leave  an  insufficient  area  of  attachment  to 
provide  the  necessary  nutrition  and  oxygen  for  the   foetus,   the 


68o  THE  PATHOLOGY  OF  PREGNANCY 

latter  dies.  In  most  cases,  this  event  will  determine  the  onset 
of  labour,  but  in  some  cases  a  condition  analogous  to  missed 
abortion  results,  and  the  ovum  is  retained  in  utero.  In  the  latter 
case,  decomposition  may  result,  if  the  membranes  are  ruptured  ; 
or,  on  the  other  hand,  if  they  remain  intact,  the  foetus  may 
merely  macerate  or  mummify  aseptically.  On  the  other  hand, 
if  there  is  still  a  sufficient  area  of  placenta  intact  to  keep  the 
foetus  alive,  the  latter  continues  to  grow.  If  the  foetus  lives  and 
the  haemorrhage  is  external,  the  uterus  increases  in  size  in  pro- 
portion to  the  advance  of  pregnancy.  If  the  foetus  dies,  the 
haemorrhage  being  still  external,  the  uterus  diminishes  in  size  as 
the  liquor  amnii  is  absorbed,  and  the  symptoms  due  to  the 
retention  of  a  dead  foetus  appear  ;  the  breasts  become  flaccid, 
any  secretion  which  may  have  appeared  in  them  disappears, 
and  the  subjective  symptoms  of  pregnancy  lessen.  If  the  haemor- 
rhage is  internal  and  the  foetus  dead,  the  patient  suffers  in  the 
same  manner  from  the  retention  of  the  foetus,  but  the  uterus 
increases  in  size.  In  such  cases,  there  is  great  difficulty  in 
feeling  the  foetal  parts  ;  and  the  uterus,  which  ordinarily  in 
haemorrhage  is  softer  than  usual,  will,  if  the  bleeding  is  excessive, 
become  tense  and  hard.  Finally,  if  the  membranes  have  ruptured 
and  saprophytic  germs  have  found  their  way  into  the  cavity,  the 
foetus  decomposes  and  a  foetid  discharge  results. 

Accordingly,  we  may  sum  up  the  symptoms  as  follows  : — A 
varying  amount  of  haemorrhage,  either  external  or  internal  ;  a 
gradual  increase  in  the  size  of  the  uterus,  if  the  foetus  lives  and 
the  haemorrhage  is  external  ;  a  diminution  in  size,  if  the  foetus 
dies  and  the  haemorrhage  is  external ;  a  more  or  less  marked 
and  sudden  increase,  if  the  haemorrhage  is  internal ;  and  a  putrid 
discharge,  if  the  foetus  decomposes. 

Diagnosis. — The  diagnosis  of  external  haemorrhage  is  obvious. 
The  diagnosis  of  internal  haemorrhage  is  made  by  noting  the 
increase  in  size  of  the  uterus — an  increase  which  enlarges  the 
uterus  out  of  proportion  to  the  period  of  pregnancy,  by  the 
difficulty  in  feeling  the  foetal  parts,  and  by  the  general  condition 
of  the  patient.  Internal  haemorrhage  at  this  stage  of  pregnancy 
is  most  likely  to  be  confused  with  vesicular  mole,  but  here  a 
mistake  in  diagnosis  is  not  of  any  great  importance,  as,  in  either 
case,  the  uterus  must  be  emptied.  The  nature  of  the  discharge 
will  in  most  cases  enable  a  distinction  to  be  made,  as,  in  haemor- 
rhage from  placental  detachment,  the  discharge  is  grumous  and 
contains  clots ;  while,  in  vesicular  mole,  it  is  thin  and  watery  and 
may  contain  small  grape-like  cysts. 

Treatment. — The  treatment  of  these  cases  is  palliative  or  active, 
according  to  their  nature.  If  the  haemorrhage  is  slight,  and  there 
is  no  evidence  that  the  foetus  is  dead,  every  effort  must  be  made 
to  check  the  bleeding  by  any  means  short  of  emptying  the  uterus. 
The  main  factor  in  attaining  this  end  is  absolute  rest  in  bed  for 
at  least  ten  days  or  a  fortnight  after  the  haemorrhage  has  ceased. 


HEMORRHAGES  OF  THE  SECOND  THREE  MONTHS        681 

A  mixture  containing  fifteen  minims  of  Ext.  Ergotae  Liq.  and 
five  minims  of  Liq.  Strychninae  may  be  given,  as  has  been  recom- 
mended in  certain  cases  of  threatened  abortion. 

Active  treatment,  consisting  in  the  emptying  of  the  uterus,  is 
indicated  under  the  following  conditions  : — If  it  is  obvious  that 
the  patient  has  lost  as  much  blood  as  is  safe  ;  if  the  discharge 
is  fcetid  ;  or,  if  the  foetus  is  dead. 

If  the  indication  for  delivery  is  haemorrhage  alone,  and  there 
is  no  sign  of  intra-uterine  decomposition,  the  easiest  method  of 
emptying  the  uterus  consists  in  first  passing  as  many  sea-tangle 
tents  into  the  cervix  as  the  latter  will  hold,  after  carefully  dis- 
infecting the  external  genitals  and  vagina,  and  then  in  plugging 
the  vagina  tightly  with  iodoform  gauze.  It  is  better  to  use  a 
number  of  small  tents  in  preference  to  a  couple  of  large  ones,  as 
the  dilating  effect  of  the  former  is  superior.  The  plug  and  tents 
are  to  be  removed  in  twenty-four  hours,  or  sooner  if  uterine  con- 
tractions ensue.  If  there  is  no  appearance  of  the  latter  when  the 
tents  are  removed,  it  will  be  well  to  rupture  the  membranes,  to 
draw  down  a  foot  into  the  vagina,  and  either  to  leave  the  further 
expulsion  to  the  uterine  contractions,  or  to  complete  the  delivery 
of  the  foetus.  In  all  cases,  if  contractions  do  not  follow  the 
rupture  of  the  membranes  within  four  to  six  hours,  it  is  best  to 
empty  the  uterus,  as  there  is  always  a  danger  of  decomposition 
occurring  if  we  wait  too  long.  An  alternative  treatment  to  the 
use  of  sea-tangle  tents  is  the  plugging  of  the  utero-vaginal  canal 
with  iodoform  gauze  after  the  method  of  Diihrssen.  To  do  this, 
the  cervix  is  drawn  down  by  means  of  an  American  forceps  on 
both  lips,  and  is  dilated  with  Hegar's  dilators  as  far  as  possible 
without  laceration.  The  end  of  a  long  strip  of  iodoform  gauze, 
two  inches  wide,  and  either  single  or  double,  according  to  the 
size  of  the  cervical  canal,  is  passed  by  means  of  a  sound  as  far 
into  the  uterus  as  possible.  This  is  followed  by  the  remainder 
of  the  strip,  and  when  it  is  finished,  by  another  similar  strip, 
which  is  knotted  on  to  the  first.  Each  bit  of  gauze  is  passed 
as  high  into  the  uterus  as  possible,  and  the  maximum  amount  is 
introduced.  As  soon  as  the  cavity  is  filled,  the  vagina  is  plugged 
tightly.  This  plug  is  left  in  situ  for  twenty-four  hours,  or  until 
strong  labour  pains  ensue,  and  is  then  removed.  The  advantage 
of  this  method  is  that  all  haemorrhage  is  checked,  that  intra- 
uterine decomposition  is  prevented,  and  that,  even  if  labour  does 
not  follow  its  removal,  it  causes  sufficient  dilatation  of  the  cervix 
to  permit  of  the  easy  extraction  of  the  foetus. 

In  those  cases  in  which  haemorrhage  is  complicated  by  the 
occurrence  of  decomposition,  the  emptying  of  the  uterus  must 
be  carried  out  at  one  sitting.  This  is  always  a  more  or  less 
troublesome  operation,  owing  to  the  small  size  of  the  cervix,  and 
frequently  it  will  only  be  possible  to  extract  the  child  after  some 
proceeding  akin  to  embryotomy.  The  author  has  found  the 
following  plan  to  be  rapid  and  comparatively  easy,  provided  that 


682  THE  PATHOLOGY  OF  PREGNANCY 

pregnancy  has  not  advanced  beyond  the  early  part  of  the  fifth 
month  : — Disinfect  the  vagina  thoroughly,  and  dilate  the  cervix 
as  far  as  possible  with  Hegar's  dilators.  Pass  one  finger  into 
the  uterus,  seize  one,  or  if  possible  both  feet,  and  draw  them 
down  as  far  as  possible,  which  will  usually  be  until  the  breech 
comes  into  the  cervical  canal.  As  soon  as  they  cannot  be  drawn 
down  any  further,  introduce  a  Schultze's  spoon-forceps,  or  other 
forceps  of  a  similar  shape,  into  the  uterus  alongside  the  breech, 
and  catch  the  latter  and  pull  it  down.  This  will  result  in  the 
tearing  off  of  part  of  it,  and  then  a  fresh  hold  is  taken,  and 
so  on  until  the  body  of  the  child  is  extracted  piecemeal.  The 
head  will  be  found  the  most  difficult  to  remove,  as  it  has  the 
largest  diameter,  but  by  means  of  the  forceps  it  can  be  crushed 
and  so  extracted.  A  Schultze's  spoon-forceps  is  a  very  safe 
instrument  for  this  procedure,  as,  owing  to  its  shape,  it  has  no 
tendency  to  catch  the  uterine  walls,  while  it  easily  seizes  any- 
thing which  is  lying  in  the  cavity.  As  soon  as  the  foetus  has 
been  entirely  removed,  the  finger  is  again  passed  into  the  uterus 
and  the  placenta  detached,  while  counter-pressure  is  made  upon 
the  fundus  by  the  hand  placed  on  the  abdominal  wall.  The 
uterus  is  then  well  douched  with  creolin  lotion  (i  in  320),  or 
other  antiseptic,  and  the  cavity  plugged  with  iodoform  gauze. 
The  latter  must  be  removed  in  from  twelve  to  twenty-four  hours, 
and  the  uterus  again  douched  if  there  is  any  rise  of  temperature. 
Prognosis. — The  prognosis  in  these  cases  is  good  unless  the 
patient  has  been  already  much  weakened  by  constant  haemor- 
rhage, or  unless  she  has  absorbed  an  excessive  dose  of  toxins 
from  the  decomposed  foetus.  To  avoid  the  danger  of  such  an 
occurrence,  the  uterus  must  always  be  emptied  as  soon  as  any 
of  the  indications  for  active  treatment,  as  given  above,  show 
themselves. 


HEMORRHAGES  OCCURRING  DURING  THE  LAST 
FOUR   MONTHS 

Haemorrhages  occurring  during  the  last  four  months  are 
divided  into  two  great  classes  : — 

I.  Accidental  haemorrhage,  due  to  the  detachment  of  a 
normally  situated  placenta. 

II.  Unavoidable  haemorrhage,  due  to  the  detachment  of  a 
placenta  praevia. 

Accidental  Hemorrhage. 

Accidental  haemorrhage  is  the  term  applied  to  haemorrhage 
due  to  the  detachment  of  a  normally  seated  placenta — i.e.,  a 
placenta  no  part  of  which  comes  into  the  lower  uterine  segment. 

Frequency. — The  frequency  of  accidental  haemorrhage  is  very 
difficult  to  ascertain,  on  account  of  the  cursory  manner  in  which 


THE  CAUSES  OF  ACCIDENTAL   HEMORRHAGE  683 

che  subject  is  treated  in  the  majority  of  text-books.  At  the  Rotunda 
Hospital,  amongst  15,109  cases  of  labour  there  were  113  cases 
of  accidental  haemorrhage — i.e.,  one  in  every  133-7  cases.  Almost 
all  these  were  cases  of  external  accidental  haemorrhage. 

.Etiology. — The  causes  of  accidental  haemorrhage  are  akin  to 
the  causes  of  abortion.  In  former  days,  they  were  divided  into 
predisposing  and  exciting  causes,  and  as  the  exciting  causes  were 
the  more  obvious,  the  greater  importance  was  attributed  to  them. 
Given  the  necessary  predisposing  causes,  anything  may  be  an 
exciting  cause  which  tends  to  cause  a  sudden  rise  in  blood- 
pressure,  and  so  may  determine  the  onset  of  the  haemorrhage. 
In  the  number  of  such  causes  may  be  included  a  fall,  sudden 
mental  emotion,  coughing,  or  any  form  of  abdominal  straining, 
etc.  The  foregoing  are,  however,  incapable  of  causing  detach- 
ment of  the  placenta  when  the  attachment  of  the  latter  to 
the  uterus  is  normal,  and,  moreover,  cannot  be  avoided  even 
if  the  attachment  is  abnormal.  They  therefore  are  of  quite 
secondary  importance  to  the  causes  which  permit  such  slight 
incidents  to  break  down  the  attachment  between  the  placenta 
and  the  uterus. 

The  most  frequent  cause  of  detachment  of  the  placenta  is  to 
be  found  in  any  factor  which  weakens  or  breaks  down  the  ad- 
hesions between  the  placenta  and  the  uterine  wall.  Decidual 
endometritis  is  probably  the  most  common  of  such  factors,  and, 
indeed,  some  authorities — notably  Kaltenbach  and  Veit* — main- 
tain that  in  all  placentae  which  separate  prematurely  there  must 
be  serotinal  inflammation  or  degeneration.  Renal  disease  is 
another  common  cause,  though  whether  it  brings  about  its  effect 
by  giving  rise  to  a  decidual  endometritis,  or  whether  it  causes 
infarction  of  the  placenta,  which  infarctions  cause  detachment 
and  haemorrhage,  is  not  certain.  Winter,!  who  first  drew  atten- 
tion to  the  association  of  accidental  haemorrhage  and  nephritis, 
found  the  latter  condition  and  endometritis  concomitant.  French 
writers  have  also  been  able  to  trace  a  very  close  connection 
between  the  two  conditions,  as  in  the  Clinique  Baudelocque  albu- 
minuria was  present  in  twenty-four  out  of  thirty-one  cases  of 
placental  detachment.  It  is  probable  that  red  infarction  of  the 
placenta  has  a  close  association  with  nephritis,  and  that,  if  ex- 
tensive, it  may  be  responsible  for  causing  the  detachment  of  the 
placenta. 

Syphilis  of  the  placenta  may  also  give  rise  to  detachment,  but 
it  is  probably  not  so  common  a  cause  as  has  been  suggested. 

Holmes,;;  in  an  interesting  article  on  accidental  haemorrhage, 
summarises  the  causes  that  he  found  assigned  to  the  detachment 
in  a  hundred  and  fifty-six  collected  cases.  Of  his  cases,  8o*8  per 
cent,  occurred  in  multiparae,  19*2  in  primiparae.     Kidney  changes 

*  Miiller's  '  Handbuch  fur  Geburt.,'  vol.  ii  ,  p.  86. 

f  Zcitschvift  fur  Geburt.  u.  Gynak.,  1884,  vol.  xi.,  p.  356. 

I  American  Jouvn.  of Obstet.,  December,  1901,  p.  753. 


684  THE  PATHOLOGY  OF  PREGNANCY 

were  noted  in  twenty  cases,  and  placental  changes  in  connection 
with  kidney  lesions  in  nine  cases.  Other  placental  changes  were 
noted  in  nineteen  cases,  of  which  six  were  'apoplexies,'  five  fatty 
degeneration,  four  syphilis  and  infarcts,  two  decidual  endometritis, 
one  diffuse  arteritis,  and  one  chorionic  degeneration. 

Traumata  of  sufficient  violence  to  produce  the  detachment  of 
the  placenta  must  also  be  included  as  causes  of  accidental 
haemorrhage.  They  may  occur  as  a  violent  blow,  or  fall,  on  the 
abdomen,  or  in  consequence  of  forcible  traction  on  the  placenta 
during  the  expulsion  of  a  foetus  whose  cord  is  too  short.  Acci- 
dental haemorrhage  may  also  occur  in  hydramnios,  owing  to  the 
detachment  of  the  placenta,  in  consequence  of  the  rapid  diminu- 
tion that  occurs  in  the  size  of  the  uterus  when  the  liquor  amnii 
suddenly  escapes. 

Varieties. — Two  chief  forms  of  accidental  haemorrhage  are  met 
with,  according  as  the  blood  escapes  externally,  or  is  stored  up  in 
the  uterus.     These  are  : — ■ 

(A)  Concealed  accidental  haemorrhage. 

(B)  External  accidental  haemorrhage. 

These  two  varieties  differ  so  markedly  from  one  another,  as  far 
as  the  conditions  present  and  the  appropriate  treatment  are  con- 
cerned, that  they  must  be  described  separately. 

Concealed  Accidental  Hemorrhage. — Concealed  accidental 
haemorrhage  is  the  term  applied  to  accidental  haemorrhage  when 
the  blood  is  stored  up  in  the  uterus  instead  of  escaping  into  the 
vagina.  In  such  a  condition,  the  blood  may  be  found  in  one  of 
four  situations  : — ■ 

(i)  Behind  the  placenta,  the  whole  of  which  is  separated 
except  its  edges. 

(2)  Behind  the  membranes,  which  are  detached  except  round 

the  internal  os. 

(3)  In  the  amniotic  cavity. 

(4)  Behind  the  presenting  part,  if  the  latter  fills  the  lower 

uterine  segment  completely. 
Concealed  accidental  haemorrhage  is,  with  the  exception  of 
acute  sepsis,  the  most  serious  accident  which  can  happen  to  a 
pregnant  woman.  This  is  due  not  only  to  the  difficulty  of 
diagnosing  its  occurrence  at  an  early  stage,  but  also  to  the  fact 
that  we  have  an  entirely  different  condition  of  the  uterus  from 
that  which  we  find  in  external  haemorrhage.  In  concealed 
haemorrhage,  the  blood  collects  in  the  uterus,  because  the  latter 
dilates  so  easily  that  the  intra-uterine  pressure  is  never  sufficiently 
great  to  overcome  the  slight  resistance  offered  to  the  outflow 
of  blood  through  the  cervix.  In  external  haemorrhage,  quite  the 
opposite  is  the  case.  Here,  the  intra-uterine  pressure  is  so 
rapidly  raised,  by  the  escape  of  blood  from  behind  the  placenta, 
that  such  blood  is  almost  immediately  forced  through  the  cervix. 
The  cause  of  the  difference  in  the  two  cases  is,  that,  in  internal 


SYMPTOMS  OF  CONCEALED  ACCIDENTAL  HEMORRHAGE    685 

haemorrhage,  we  have  to  deal  with  a  uterus  the  muscle  fibre  of 
which  has  for  some  reason  lost  its  normal  contractile  tone,  and 
whose  elasticity  is,  as  a  result,  impaired  ;  while,  in  external 
haemorrhage,  the  uterine  fibre  possesses  that  normal  tone,  and 
hence  may  be  described  as  'healthy.'  It  is  quite  obvious  that 
a  ruptured  vessel  can  only  bleed  into  a  closed  cavity  as  long  as 
the  pressure  inside  that  cavity  is  less  than  the  blood- pressure. 
Once  the  intra-uterine  pressure  equalises  the  blood-pressure,  the 
bleeding  ceases.  If  the  blood  can  escape  from  the  cervix  as 
quickly  as  it  flows  from  behind  the  placenta,  then  such  equalisa- 
tion never  takes  place.  If  the  uterus  is  healthy  in  tone,  and 
the  outflow  of  blood  from  the  cervix  is  prevented,  the  two 
pressures  rapidly  equalise  one  another,  and  the  bleeding  ceases. 
If,  however,  the  uterine  fibre  has  lost  its  tone  to  such  an  extent 
that  it  permits  the  uterus  to  dilate  before  the  blood-pressure, 
then  not  only  does  the  intra-uterine  pressure  never  rise  sufficiently 
to  check  the  haemorrhage,  but  it  is  not  even  sufficient  to  force 
the  blood  which  has  escaped  through  the  cervix.  In  this  manner, 
concealed  haemorrhage  commences.  The  amount  of  haemorrhage 
which  the  uterus  will  permit  to  accumulate  in  its  cavity  depends 
upon  the  extent  to  which  the  muscle  fibre  is  affected.  The 
first  sign  that  the  latter  is  commencing  to  react  against  the 
distension  it  is  undergoing,  is  the  escape  of  blood  externally, 
and  accordingly  the  earlier  in  the  haemorrhage  that  escape  occurs, 
the  healthier  may  the  condition  of  the  uterus  be  judged  to  be. 
These  are  all  important  facts  to  grasp,  as  they  explain  the 
essential  differences  between  external  and  internal  haemorrhages 
so  far  as  accompanying  conditions  go.  They  also  indicate  a  line 
of  treatment  by  which  external  haemorrhage  may  be  checked, 
and  the  necessity  for  uterine  co-operation  in  carrying  out  such  a 
treatment. 

Symptoms. — The  symptoms  of  concealed  haemorrhage  fall  under 
two  heads  : — 

(1)  Those  due  to  the  loss  of  blood,  and  common  to  all  forms 

of  haemorrhage. 

(2)  Those  due  to  the  accumulation  of  blood  in  the  uterus. 

(1)  The  symptoms  included  in  the  first  group  do  not  require 
any  special  description  here.  They  will  be  referred  to  in  full 
when  dealing  with  post-haemorrhagic  collapse. :;: 

(2)  The  most  prominent  symptom  in  the  second  group  consists 
in  the  gradual  enlargement  of  the  uterus,  which  may  dilate  to 
such  an  extent  as  to  fill  the  entire  abdomen  and  cause  pressure 
on  the  diaphragm.  The  uterus  at  first  becomes  tense,  and  then 
of  an  almost  woody  hardness,  and  is  "markedly  tender  to  the 
touch.  It  is  difficult  or  impossible  to  palpate  the  foetus.  At  the 
same  time,  there  is  severe  abdominal  pain,  akin  to  the  pain  caused 
by  the  tonic  contraction  of  the  uterus  in  cases  of  threatened 
rupture. 

*   Vide  Part  VII.,  chap  vii. ,  Post-partum  Haemorrhage. 


686  THE  PATHOLOGY  OF  PREGNANCY 

Diagnosis. — The  diagnosis  of  concealed  haemorrhage  due  to 
detachment  of  the  placenta  can  be  made  by  means  of  the  symp- 
toms given  above.  Tenderness  of,  and  increase  of  size  in,  the 
uterus,  with  ever-increasing  pain,  are  almost  pathognomonic  of 
concealed  haemorrhage — an  important  fact  to  bear  in  mind  even 
when  there  is  a  sufficient  amount  of  external  haemorrhage  to 
account  for  any  other  symptoms, 

Treatment. — The  treatment  of  concealed  haemorrhage  is  so  far 
by  no  means  satisfactory.  Mild  cases  which  occur  during  labour 
are  not  very  difficult  to  treat,  but  severe  cases  starting  prior  to 
the  onset  of  labour  are  most  serious.  From  what  we  know 
of  the  aetiology  of  the  condition,  it  is  obvious  that  plugging  of  the 
vagina — a  line  of  treatment  which  is  so  satisfactory  in  external 
haemorrhage — is  here  of  little  avail.  In  those  cases  in  which 
we  are  able  to  recognise  the  very  commencement  of  the  haemor- 
rhage, some  good  may  be  gained  by  the  application  of  a  tight 
abdominal  binder  and  possibly  by  the  administration  of  ergot, 
while  the  application  of  a  firm  vaginal  compress  —  as  will  be 
presently  described — may  bring  on  labour  before  the  haemorrhage 
has  reached  a  formidable  amount.  Once  the  patient"  begins  to 
have  strong  uterine  contractions,  a  great  deal  of  the  risk  of  the 
case  disappears.  Rupture  of  the  membranes  is  then  indicated, 
with  the  object  of  permitting  the  blood  to  escape  and  the  uterus 
to  contract  down  upon  the  foetus.  The  remaining  treatment 
of  the  case  is  the  same  as  that  of  external  accidental  haemor- 
rhage occurring  when  the  patient  is  in  labour.  Unfortunately, 
many  cases  of  concealed  haemorrhage  occur  before  the  patient 
is  in  labour,  and  do  not  admit  of  any  temporising  measures.  In 
such  cases,  the  bleeding  must  be  immediately  checked,  and,  in 
order  to  do  this,  the  seat  of  the  haemorrhage  must  be  directly 
reached.  Two  lines  of  treatment  present  themselves — accouchement 
force,  and  supra- vaginal  amputation  of  the  uterus  either  by  Porro's 
method  or  not,  as  may  be  preferred.  These  are  both  most 
serious  measures,  and  convey  per  se  a  great  element  -of  danger 
into  the  case.  The  only  excuse  for  their  adoption  is  that  the 
danger  which  they  are  directed  against  is  so  urgent  that  even 
the  risk  of  Porro's  operation,  or  accouchement  force,  is  to  be 
preferred. 

By  accouchement  force  is  meant  the  dilatation  of  the  cervix, 
followed  by  version  and  the  extraction  of  the  foetus.  Dilatation 
was  formerly  usually  effected  by  means  of  radiating  incisions 
through  the  walls  of  the  cervical  canal,  or  with  the  fingers. 
Bossi's  dilator,  or  one  of  its  modifications,  now,  however,  offers  a 
better  means  of  effecting  dilatation,  and,  it  may  be,  will  cause  a 
considerable  improvement  in  the  rate'  of  mortality  in  these  cases. 
As  soon  as  the  whole  hand  can  be  passed  into  the  uterus,  the 
foot  of  the  foetus  is  seized  and  drawn  down.  By  gradually 
pulling  upon  the  latter,  the  size  of  the  cervical  canal  is  still 
further  increased,  and  finally  the  breech  can  be  brought  through. 


EXTERNAL  ACCIDENTAL  HEMORRHAGE  687 

The  remainder  of  the  foetus  is  then  extracted  in  the  usual  manner. 
If  the  placenta  is  not  immediately  expelled  by  the  uterine  con- 
tractions, it  should  be  removed  by  the  hand,  and  in  all  cases  the 
utero  vaginal  canal  must  be  plugged  firmly  with  iodoform  gauze. 

Supra-vaginal  amputation  of  the  uterus,  if  there  is  sufficient 
assistance,  is  quicker  than  the  foregoing,  if  Porro's  operation  is 
performed.  There  is  less  blood  lost  during  its  performance, 
and  there  is  but  little  more  shock.  The  objection  to  it  is  the 
greater  number  of  assistants  and  the  extent  of  the  preparations 
which  it  requires.  Porro's  operation  is  the  most  rapid  method, 
but  convalescence  is  slower  than  if  retro-peritoneal  treatment  of 
the  stump  is  adopted.  In  the  past,  supra-vaginal  hysterectomy 
has  perhaps  offered  the  better  prospect  of  saving  the  life  of  the 
patient  in  serious  cases,  but  we  are  inclined  to  think  that,  in 
future,  dilatation  by  Bossi's  or  Frommer's  dilator,  followed  by 
extraction,  will  yield  better  results.  It  may  also  be  that  partial 
dilatation  of  the  cervical  canal  in  order  to  give  the  necessary 
space,  followed  by  the  packing  of  the  uterus  tightly  with  iodoform 
gauze,  may  prove  successful  in  checking  the  haemorrhage.  If 
it  did  so,  it  would  materially  improve  the  prognosis,  as  it  would 
afford  the  patient  time  to  rally  from  her  state  of  collapse  before 
expulsion  of  the  foetus  occurred. 

Prognosis.  —  The  prognosis  for  the  mother  is  very  serious, 
especially  in  those  cases  which  come  on  before  labour  starts  ; 
for  the  child  it  is  almost  absolutely  bad. 

External  Accidental  Hemorrhage.  —  External  accidental 
haemorrhage  is  the  term  applied  to  accidental  haemorrhage  when 
the  blood  escapes  from  the  uterus  according  as  it  is  poured  out 
from  behind  the  detached  placenta.  It  is  a  serious  accident,  but 
by  no  means  as  serious  as  is  concealed  haemorrhage.  In  the 
majority  of  cases  the  blood  pours  into  the  vagina  as  rapidly  as 
it  escapes  from  the  ruptured  vessels.  Sometimes,  however,  a 
certain  amount  of  blood  may  first  accumulate  in  the  uterus,  and 
then  commence  to  escape  externally  as  soon  as  the  latter  reacts 
against  the  blood-pressure — i.e.,  as  soon  as  the  intra-uterine 
pressure  becomes  sufficiently  great  to  overcome  the  resistance 
to  the  escape  of  blood. 

Symptoms. — The  escape  of  blood  from  the  vagina  is  the  most 
marked  symptom,  accompanied  by  the  usual  symptoms  of 
collapse  if  the  bleeding  continues  long  enough.  In  those  cases 
in  which  there  is  concealed  haemorrhage  as  well,  the  symptoms 
which  have  been  given  under  the  head  of  concealed  haemorrhage 
are  also  present,  though  usually  to  a  less  degree. 

Diagnosis. — The  diagnosis  of  the  case  has  to  be  made  from 
haemorrhage  due  to  placenta  praevia — i.e.,  unavoidable  haemor- 
rhage. To  do  this,  examine  the  patient  vaginally,  with  the 
object  of  determining  whether  the  placenta  can  be  felt  in  the 
lower  uterine  segment  or  not.     If  it  can  be  felt,  it  is  a  case  of 


688  THE  PATHOLOGY  OF  PREGNANCY 

placenta  praevia,  if  it  cannot,  of  accidental  haemorrhage.  In 
some  cases  in  which  the  placenta  cannot  be  felt,  it  may  possibly 
be  a  case  of  lateral  placenta  previa,  but  still  it  is  to  be  treated  as 
if  it  was  one  of  accidental  haemorrhage.  The  reason  for  this  is 
that,  if  the  placenta  lies  so  far  from  the  cervix  that  it  cannot  be 
felt  from  the  vagina,  though  actually  the  case  may  be  one  of 
placenta  praevia,  still  the  treatment  suitable  for  accidental 
haemorrhage  will  be  found  to  be  the  more  efficacious. 

Accidental  haemorrhage  may  be  diagnosed  by  abdominal  pal- 
pation by  excluding  the  possibility  of  placenta  praevia.  If  the 
head  is  found  to  be  fixed  in  the  pelvis,  the  case  is  certainly 
not  one  of  placenta  praevia. 

Treatment. — The  treatment  of  the  case,  as  well  as  the  prognosis, 
depend  to  a  very  great  extent  upon  the  time  at  which  the 
haemorrhage  starts,  i.e.,  whether  during  pregnancy  or  labour — 
when  there  are  no  uterine  contractions,  or  when  there  are.  If 
the  patient  is  in  labour,  the  danger  of  the  case  is  greatly 
diminished,  and  the  treatment  is  comparatively  simple.  If  she 
is  not  in  labour,  the  reverse  is  the  case. 

If  the  patient  is  not  in  labour  when  the  haemorrhage  starts, 
there  are  two  points  towards  which  our  treatment  must  be 
directed.  The  first  is  the  immediate  checking  of  the  haemor- 
rhage ;  the  second  is  the  induction  of  labour.  If  the  haemorrhage 
can  be  satisfactorily  stopped  for  the  time  necessary  to  bring  on 
uterine  contractions,  the  case  is  practically  reduced  to  one  01 
haemorrhage  during  labour,  and  the  prognosis  consequently  im- 
proved. As  has  been  shown  above,  there  is  very  little  room  for 
blood  to  accumulate  in  a  '  healthy  '  uterus -filled  by  an  unruptured 
ovum,  and  the  blood  either  escapes  from  the  cavity  as  rapidly  as  it 
pours  out  from  behind  the  placenta,  or  the  intra-uterine  pressure 
becomes  equal  to  the  blood-pressure,  and  the  bleeding  ceases. 
Therefore,  if  the  uterus  is  '  healthy,'  and  if  we  prevent  the  blood 
which  is  being  poured  out  from  behind  the  placenta  from 
leaving  the  uterus,  the  pressure  inside  the  latter  will  rapidly 
become  equal  to  the  blood-pressure,  and  the  haemorrhage  will 
cease.  The  question  then  arises,  How  can  we  tell  whether  the 
uterus  is  or  is  not  healthy  ?  Clinically,  we  think,  this  is  answered 
by  the  variety  of  haemorrhage  that  has  occurred,  and  that  the 
fact  that  the  haemorrhage  is  external  shows  that  the  uterus  is 
'  healthy.'  The  results  of  cases  treated  by  the  vaginal  tampons  at 
the  Rotunda  Hospital  supports  this  belief,  as  in  no  case  has 
plugging  converted  an  external  into  an  internal  haemorrhage, — an 
accident  which  would  surely  have  occurred  if  the  uterine  fibre  had 
lost  its  tone.  The  easiest  and  most  effectual  method  of  pre- 
venting the  escape  of  blood  is  by  plugging  the  vagina  tightly,  and 
so  compressing  the  cervix.  This  will  check  the  haemorrhage, 
and  at  the  same  time  it  will  carry  out  our  other  object,  which 
is  a  necessary  part  of  any  successful  treatment — namely,  it  will 
induce  labour.      Furthermore,  labour  thus  brought  on  comes  on 


THE  TREATMENT  OF  ACCIDENTAL  HEMORRHAGE         6S9 

gradually,  and  does  not  cause  any  aggravation  of  the  shock 
from  which  the  patient  is  already  suffering,  as  do  the  more  rapid 
methods  of  emptying  the  uterus.  On  the  contrary,  ample  time 
is  allowed  for  the  patient  to  rally  from  the  collapse,  which  the 
haemorrhage  has  caused,  before  the  uterus  empties  itself.  The 
plugging  is  continued  until  no  more  can  be  pressed  into  the 
vagina.  The  patient  is  then  put  back  to  bed,  and  an  abdominal 
binder  pinned  as  tightly  as  possible  round  the  uterus,  while  a 
T-binder  is  brought  down  between  the  thighs,  and  also  fixed 
firmly.  By  this  means,  the  uterus  is  compressed  between  the 
plug  in  the  vagina  and  the  abdominal  binder,  and  the  intra- 
uterine pressure  is  raised.  The  plug  is  left  in  until  strong  labour 
pains  ensue,  and  this  usually  occurs  in  from  two  to  four  hours. 
In  some  cases,  the  onset  of  labour  is  slower  than  this,  and  in 
such  the  plug  must  be  removed  in  twenty-four  hours  for  fear  of 


Fig.  296. — Diagram  showing  Vaginal  Tampon  in  situ. 

decomposition  taking  place.  If  haemorrhage  comes  on  again  it 
can  be  replaced,  but  this  is  rarely  necessary.  While  the  plug  is 
in  situ  the  patient  must  be  carefully  watched,  to  see  that  con- 
cealed haemorrhage  is  not  occurring.  The  first  sign  of  such  a 
condition  is  afforded  by  the  patient  complaining  that  the  ab- 
dominal binder  is  becoming  tighter  than  she  can  bear — a  con- 
dition which  is  caused  by  the  increase  in  size  of  the  uterus. 

The  success  of  this  treatment  depends  upon  three  points  : — the 
uterus  must  be  '  healthy,'  the  ovum  must  be  intact,  and  the  plug 
must  be  tightly  applied. 

If  the  patient  is  in  labour  when  the  haemorrhage  starts,  the 
first  thing  to  be  done  is  to  rupture  the  membranes.  This  treat- 
ment, which  was  formerly  recommended  as  the  treatment  in  all 
cases,  now  becomes  permissible,  as,  in  consequence  of  the 
presence  of  uterine  contraction,  it  does  not  tend  to  lower  the 
intra-uterine  pressure.     The  object  of  this  procedure  is  to  stimu- 

44 


690  THE  PATHOLOGY  OF  PREGNANCY 

late  uterine  action  and  to  prevent  the  detachment  of  additional 
portions  of  the  placenta.  Every  time  the  uterus  contracts,  it 
drives  the  presenting  part  or  the  liquor  amnii  against  the  mem- 
branes lying  over  the  os  internum,  and  these  latter  in  turn 
communicate  this  downward  impulse  to  the  placenta.  In  this 
manner,  with  each  contraction,  while  the  membranes  are  un- 
ruptured, a  fresh  piece  of  placenta  is  detached.  When  the 
membranes  are  ruptured,  the  presenting  part  can  advance 
without  causing  any  such  drag  upon  the  placenta.  Rupture 
of  the  membranes  can  be  accomplished  by  means  of  a  stilette  or 
the  finger-nail,  and  care  must  be  taken  to  ensure  the  gradual 
escape  of  the  liquor  amnii,  especially  in  those  cases  in  which 
the  presenting  part  is  not  fixed,  lest  the  cord  should  be  carried 
down  at  the  same  time.  In  addition  to  rupturing  the  membranes, 
a  hot  vaginal  douche  may  be  given  to  stimulate  uterine  contrac- 
tions, and  massage  of  the  fundus,  with  the  same  object,  may  also 
be  tried. 

If  such  treatment  fails  to  check  the  bleeding,  our  further  plan 
of  action  depends  upon  the  size  of  the  os.  If  the  latter  is  still 
quite  small,  the  vagina  must  be  plugged  as  before.  This  treat- 
ment, which  would  be  most  unsafe  after  the  membranes  are 
ruptured  if  there  were  no  labour  pains,  becomes  again  safe  if 
there  are  strong  contractions,  as  the  latter  ensure  the  obliteration 
of  any  space  around  the  foetus,  left  by  the  escape  of  the  liquor 
amnii.  The  plug  is  left  in  situ  until  pains  of  an  expulsive 
character  set  in,  when  it  may  be  removed.  The  use  of  the 
plug  in  cases  such  as  this  is,  however,  very  seldom  required,  as 
in  the  large  majority  of  cases  haemorrhage  ceases  when  the  mem- 
branes are  ruptured  in  the  presence  of  uterine  contractions,  or 
else  it  is  possible  to  empty  the  uterus.  If  the  os  is  half  or  more 
dilated,  and  the  presenting  part  is  not  fixed,  podalic  version, 
followed  by  extraction,  is  the  line  of  treatment  indicated.  If, 
however,  the  patient  is  very  much  collapsed,  and  all  haemorrhage 
ceases  as  soon  as  a  foot  has  been  brought  down  into  the  cervical 
canal,  it  may  be  advisable  to  leave  the  expulsion  of  the  child  to 
the  natural  efforts.  Version  in  these  cases  can  usually  be  carried 
out  by  the  internal  method,  but  in  some  cases  it  may  be  necessary 
to  adopt  the  bi-polar  method,  owing  to  the  small  size  of  the 
cervical  canal.  If,  on  the  other  hand,  the  os  is  fully  or  almost 
fully  dilated  and  the  head  is  fixed,  immediate  extraction  by  the 
forceps  is  indicated. 

Other  Modes  of  Treatment. — The  foregoing  is  the  treatment  which 
we  recommend,  and  our  reason  for  so  doing  will  be  found  below. 
But,  in  addition,  there  are  other  methods  which  are  recommended 
by  various  authorities.     Of  these  the  following  are  the  chief : — 

Rupture  of  the  Membranes  in  every  case. — Rupture  of  the 
membranes  in  every  case  is  the  treatment  which  formerly  had 
the  greatest  number  of  supporters.  It  is  a  treatment  which  is 
easily  carried   out,  and  in  some  cases  is  sufficient.     If  we  can 


> 


THE  TREATMENT  OF  ACCIDENTAL  HEMORRHAGE        691 

be  certain  that  the  uterus  will  contract  down  upon  the  fcetus, 
immediately  after  the  escape  of  the  liquor  amnii,  there  are  no 
very  great  objections  to  trying  such  a  course  of  action,  as  if  it 
fails  it  is  still  possible  to  resort  to  plugging.  But,  if  the  uterus 
does  not  contract  down  upon  the  foetus,  there  is  a  large  space  left 
inside  it  for  blood  to  collect  in,  and  as  plugging  is  then  contra- 
indicated,  if  the  haemorrhage  continues,  there  is  nothing  left  but 
accouchement  force — the  most  dangerous  of  all  lines  of  treatment. 
Accordingly,  rupture  of  the  membranes  should  only  be  performed 
in  those  cases  in  which  we  can  be  certain  that,  after  it  is  done, 
the  uterus  will  contract  down  upon  the  foetus ;  that  is,  it  should 
only  be  performed  when  the  patient  is  in  labour. 

Accouchement  Force. — Accouchement  force  is  the  most  dangerous 
of  all  lines  of  treatment,  and  is  unjustifiable  in  any  case  of 
external  haemorrhage  so  long  as  the  membranes  are  intact. 
The  great  objection  to  it  lies  in  the  fact  that  intra-uterine 
manipulations,  particularly  the  violent  manipulations  of  accouche- 
ment force,  tend  directly  to  aggravate  the  collapse  which  the 
haemorrhage  causes.* 

Prognosis. — The  prognosis  in  external  accidental  haemorrhage 
depends  very  much  on  the  form  of  treatment  adopted.  In  the 
Rotunda  Hospital,  fifty-six  cases  of  accidental  haemorrhage  of  all 
degrees  of  severity  were  treated  between  November,  1889,  and 
November,  1893.  Accouchement  force  was  the  mode  of  treatment 
adopted  in  all  the  serious  cases,  and  of  the  patients  so  treated  six 
died.  From  November,  1893,  to  November,  1900,  fifty-seven 
cases  were  treated.  Accouchement  force  was  never  performed,  its 
place  being  entirely  taken  by  plugging.  Out  of  this  number  one 
case  of  external  haemorrhage  died,  and  she  had  been  admitted  to 
the  hospital  thirty  minutes  previously  with  the  membranes 
ruptured.  The  number  of  serious  cases  during  the  two  periods 
was  proportionately  the  same.  The  treatment  by  rupture  of  the 
membranes  in  all  cases  is  credited  by  its  supporters  with  a 
mortality  of  ten  to  twelve  per  cent.,  yet  a  well-known  obstetrician 
used  to  consider,  that  the  fact  of  a  student  recommending 
plugging  of  the  vagina  as  a  treatment  for  accidental  haemorrhage 
was  sufficient  ground  for  depriving  him  of  his  examination. 
The  subject  is  so  important  that  the  writer  wishes  to  again 
state  that  the  advantages  of  the  vaginal  plug  are  as  follows  : — 
It  at  the  same  time  checks  haemorrhage  and  brings  on  labour ; 
labour  so  induced  comes  on  gradually,  and  before  delivery  the 
patient  has  had  an  interval  of  rest,  during  which  she  can  re- 
cover from  her  collapsed  condition  ;  the  vaginal  plug  applied  in 
suitable  cases  does  not  tend  'to  convert  an  external  into  an  in- 

*  For  the  most  recent  opinions  on  the  treatment  of  accidental  haemorrhage, 
see  '  Discussion  on  the  Treatment  of  Accidental  Haemorrhage,'  by  Sir 
A.  V.  Macan,  and  others  (Brit.  Med.  Journ.,  October  22,  1904,  p.  1049);  also 
Holmes'  paper,  Amer.  Journ.  of  Obstet.,  vol.  xliv. ;  and  Colclough,  Journ.  of 
Obstet.  and  Gyn.  of  the  Brit.  Empire,  August,  1902. 

44—2 


692  THE  PATHOLOGY  OF  PREGNANCY 

ternal  haemorrhage ' ;  and,  even  if  the  bleeding  continues  after 
the  plug  has  been  applied,  the  patient  is  in  no  worse  position  for 
the  adoption  of  any  other  treatment. 

The  foetal  mortality  is  very  high — from  40  to  60  per  cent.  It 
will  be  discussed  subsequently. 

Unavoidable  Hemorrhage. 

Unavoidable  haemorrhage,  or  haemorrhage  due  to  placenta 
praevia,  is  the  term  applied  to  bleeding  caused  by  the  detach- 
ment of  a  placenta,  any  portion  of  which  is  implanted  so  near  the 
os  internum,  that  it  becomes  separated  during  the  formation  of 
the  lower  uterine  segment. 

Frequency. — The  statistics  relating  to  the  frequency  of  placenta 
praevia  are  very  conflicting.  Kaltenbach  gives  the  proportion 
of  1  in  1,500  to  1,600,  Winckel  1  in  1,500,  Ribemont-Dessaignes 
1  in  1,000,  the  Boston  Lying-in  Hospital  1  in  239.  At  the 
Rotunda  Hospital,  among  20,000  cases  of  labour,  there  were 
108  cases  of  placenta  praevia,  or  1  in  185. 

JEtiology. — The  aetiology  of  placenta  praevia  is  very  obscure. 
It  is  more  frequent  amongst  multiparae  than  amongst  primiparae, 
and  is  also  relatively  more  frequent  in  the  case  of  twin  preg- 
nancies. The  many  theories  which  have  been  brought  forward 
may  be  reduced  to  two  : — 

(1)  That  the  ovum  is  implanted  in  the  uterus  at  a  lower  level 
than  is  normally  the  case,  and  that,  consequently,  when  the 
placenta  is  formed,  it  lies  nearer  the  os  internum  than  is  normally 
the  case.  Various  causes  have  been  suggested  to  account  for  the 
occurrence  of  such  a  condition.  Placenta  praevia  frequently 
occurs  in  patients  with  a  history  of  previous  attacks  of  endome- 
tritis, and  it  has  been  suggested"  that  the  increased  size  of  the 
uterine  cavity  in  the  latter  condition  allows  the  ovum,  when  it 
leaves  the  Fallopian  tube,  to  drop  into  the  lower  part  of  the 
uterus.  Webster*  brings  forward  the  very  plausible  suggestion 
that  the  low  implantation  of  the  ovum  may  be  due  to  its  fertilisa- 
tion rather  later  than  is  usually  the  case,  i.e.,  after  it  has  reached 
the  lower  part  of  the  uterus.  When  discussing  the  aetiology  of 
extra-uterine  pregnancy,  we  saw  that  it  was,  at  least,  probable 
that  fertilisation  of  the  ovum  might  occur  at  any  spot  between  the 
ovary  and  the  cervix,  but  that  it  usually  occurred  in  the  tube. 
There  is,  so  far  as  we  at  present  know,  no  reason  that  fertilisation 
should  not  occur  as  Webster  suggests — when  the  ovum  is  in  the 
neighbourhood  of  the  lower  uterine  segment,  but  it  seems  to  us 
that  if  every  such  fertilisation  resulted  in  the  formation  of  a 
placenta  praevia,  this  condition  would  be  much  more  common  than 
it  is.  This  difficulty  can,  however,  be  got  over  by  the  equally 
probable  assumption  that  when  such  late  fertilisation  of  the  ovum 
occurs  the  latter  is  as  a  rule  carried  out  of  the  uterus  before  it  has 
*  '  A  Text-Book  of  Obstetrics,'  1903,  p.  342. 


THE  ETIOLOGY  OF  PLACENTA  PRJEVIA 


693 


time  to  become  implanted  in  the  mucous  membrane,  and  that  it  is 
only  in  the  rare  cases  in  which,  for  some  cause  or  other,  the 
ovum  is  not  carried  out  of  the  uterus  that  implantation  in  the 
lower  segment  results.  Webster  and  others  possess  specimens 
of  early  pregnancies  which  clearly  show  a  primary  implantation 
of  the  ovum  near  the  os  internum. 


Fig.  297. — A  Sagittal  Section  of  the  Uterus  at  End  of  Third  Month 
of  Pregnancy,  showing  Reflexal  Placenta. 

A  considerable  portion  of  the  decidua  reflexa  is  covered  by  the  placenta, 
which  extends  in  the  anterior  part  of  the  uterus  as  low  as  the  os  internum. 

a,  Uterine  wall,  to  which  the  serotinal  placenta  is  attached;  b,  amniotic 
cavity;  c,  foetus;  d,  serotinal  placenta;  e,  urine  in  bladder;  /,  space 
between  decidua  vera  and  decidua  reflexa ;  g,  junction  of  reflexa  and 
serotina  on  anterior  wall  of  uterus  ;  h,  decidua  reflexa  free  from  placenta ; 
i,  placenta  developed  on  posterior  part  of  decidua  reflexa  ;  /,  os  internum. 
(Webster.) 

(2)  That  the  placenta  is  developed  out  of  chorionic  villi  which 
are  implanted  in   the  decidua   reflexa   as  well   as   out   of   those 


694  THE  PATHOLOGY  OF  PREGNANCY 

which  are  implanted  in  the  normal  manner  in  the  decidua  sero- 
tina,  or  that,  in  other  words,  there  is  a  reflexal  placenta  as  well 
as  a  serotinal  placenta.  This  theory  was  advanced  by  Hofmeier* 
in  1888,  and  supported  by  Kaltenbachf  in  1890,  and  has  been 
abundantly  verified  by  specimens  showing  a  reflexal  placenta. 
It  probably  accounts  for  the  occurrence  of  most  cases  of  placenta 
praevia. 

The  exciting  cause  of  haemorrhage  from  a  placenta  praevia  was 
for  a  long  time  held  to  be  the  gradual  increase  in  size  of  the 
placental  site,  the  result  of  the  formation  and  expansion  of  the 
lower  uterine  segment.  It  is,  however,  now  usually  agreed  that 
the  lower  uterine  segment  does  not  alter  until  labour  sets  in,  and, 
therefore,  this  explanation  can  only  be  accepted  in  cases  in  which 
haemorrhage  commences  with  the  onset  of  labour.  For  those  cases 
in  which  haemorrhage  starts  earlier  in  pregnancy,  another  ex- 
planation must  be  found.  Webster  regards  it  as  probable  that 
in  every  case  in  which  the  placenta  is  partly  reflexal  in  origin, 
there  is  a  tendency  all  through  pregnancy  for  degeneration  of  the 
reflexal  portion  to  occur,  with  consequent  rupture  from  thinning 
of  its  substance.  He  thinks  that  many  cases  of  abortion  are  due 
to  such  a  condition,  and  that  the  firmer  the  union  between  the 
reflexal  placenta  and  the  decidua  vera,  the  later  in  pregnancy 
will  separation  occur.  If,  on  the  other  hand,  the  low  situation 
of  the  placenta  is  due,  not  to  its  reflexal  origin,  but  to  a  primarily 
low  implantation  of  the  ovum,  haemorrhage  is  less  likely  to  occur 
until  the  onset  of  labour,  whether  this  occurs  at  full  term  or 
prematurely.  We  thus  see  that  haemorrhage  in  placenta  praevia 
may  be  started  in  one  of  several  ways  : — In  the  case  of  a  reflexal 
placenta,  it  is  probably  due  to  degenerative  changes  in,  and  ex- 
cessive thinning  of,  the  reflexal  portion,  due  to  the  increase  in 
size  of  the  ovum.  In  such  cases,  the  haemorrhage  usually 
commences  during  pregnancy,  or,  if  the  union  between  the 
reflexal  placenta  and  the  decidua  vera  is  very  dense,  it  may  not 
occur  until  full  term.  In  the  case  of  a  low  implantation  of  the 
ovum,  the  placenta  being  entirely  serotinal,  haemorrhage  as  a 
rule  is  started  by  the  commencing  dilatation  of  the  cervix  and" 
the  formation  of  the  lower  uterine  segment,  and  so  is  coincident 
with  the  onset  of  labour.  As  a  rule,  in  such  cases  the  haemorrhage 
does  not  occur  until  full  term,  but  sometimes  it  may  occur  earlier 
as  a  result  of  the  onset  of  premature  labour.  Lastly,  a  placenta 
praevia  may  be  detached  in  consequence  of  the  action  of  causes 
similar  to  those  which  bring  about  the  detachment  of  a  normally 
seated  placenta. 

In  some  cases,  haemorrhage  may  be  due  to  the  laceration  in  the 
so-called  circular  sinus  (Meckel)  of  the  placenta — that  is,  in  the 
outer  ring  of  intervillous  spaces  which  surround  the  placenta. 
The  '  sinus '  may  be  torn  even  in  cases  in  which  the  placenta  is 

*   Verh.  d.  deutschen  Gesell.  f.  Gyn.,  1888,  159-163;  and  1897,  204. 
•j-  Zeitschr.  fur  Geb.  u.  Gyn.,  1890,  xviii.,  1-7. 


THE  SYMPTOMS  OF  PLACENTA   PRMVIA  695 

normally  seated,  but  it  is  naturally  more  exposed  to  injury  during 
labour,  when  the  edge  of  the  placenta  passes  across  the  uterine 
orifice. 

Varieties. — A  placenta  praevia  is  termed  central,  marginal,  or 
lateral,  according  as  it  completely  covers  the  os,  just  reaches 
its  edge,  or  merely  extends  into  the  lower  uterine  segment  with- 
out reaching  the  inner  os.  It  is  obvious  that  these  relationships 
will  materially  alter  according  to  the  size  of  the  os.  Thus, 
what  may  be  a  central  placenta  praevia  at  the  commencement 
of  labour,  will  as  the  os  dilates  become  marginal,  and  so  it 
is  necessary  for  the  sake  of  clearness  to  specify  the  size  of  the 
os  at  the  time  at  which  the  examination  is  made.     It  is  usual  to 


Fig.  298. — Diagram  showing  Different  Situations  of  the  Placenta. 

A,  Marginal  placenta  praevia;  B,  central  placenta  praevia  ;   C,  lateral 

placenta  praevia  ;  D,  normal  situation  of  placenta. 

use  these  terms  in  connection  with  an  undilated  condition  of  the 
cervical  canal. 

Symptoms. — The  chief  symptom  is  the  occurrence  of  an  attack 
of  haemorrhage,  coming  on  without  any  apparent  cause,  and  of 
more  or  less  severity.  The  first  attack  of  haemorrhage,  if  not 
treated,  may  be  sufficiently  profuse  to  cause  the  death  of  the 
patient,  but  such  an  occurrence  is  very  rare.  More  commonly 
she  recovers  from  it,  only  to  have  a  second  attack  in  from  eight 
to  ten  days,  and  this  in  turn  is  followed  by  others.  The  haemor- 
rhage of  placenta  praevia  is,  essentially,  a  haemorrhage  of  repe- 
titions (Ribemont-Dessaignes).  As  in  accidental  haemorrhage, 
the  bleeding  is  most  severe  during  a  contraction  of  the  uterus. 
This,  in  placenta  praevia,  is  due  to  the  fact  that  the  vessels  which 
supply  the  placenta  lie  below  the  contraction  ring,  and  conse- 
quently during  a  contraction  not  only  are  they  not  compressed, 
but  the  blood-pressure  in  them  is  increased,  owing  to  the  obstruc- 


696 


THE  PATHOLOGY  OF  PREGNANCY 


tion  offered  to  the  flow  of  blood  in  branches  running  above  the 
contraction  ring.  If  the  bleeding  continues,  the  usual  symptoms 
of  collapse  appear. 

Diagnosis. — There  is  only  one  reliable  method  of  diagnosing  a 
placenta  praevia—  that  is,  by  feeling  it  through  the  cervical  canal, 
or,  if  that  is  closed,  through  the  lateral  fornices.  In  almost  all 
cases  in  which  the  occurrence  of  haemorrhage  calls  our  attention 
to  the  condition,  the  cervix  will  be  found  to  be  sufficiently  dilated 
to  admit  one  or  two  fingers,  and  so  there  is  rarely  any  difficulty 


Fig.  299. — Central  Placenta  Previa. 
C,  Cord  ;  P,  placenta  ;     L,  line  of  separation  of  placenta  ;  OI,  os  internum  ; 
B,  blood-clot  attached  to  placenta  ;  PF,   posterior  vaginal  fornix ;  AF, 
anterior  vaginal  fornix;  OE,  os  externum;  V,  vagina;  BW,  portion  of 
wall  of  bladder.     (Bumm.) 

in  determining  the  position  of  the  placenta.  The  latter  is  felt  as 
a  spongy  mass,  either  completely  covering  over  the  os  internum 
or  lying  to  one  or  other  side  of  it.  A  blood-clot,  which  has 
become  adherent  to  the  membranes  in  either  of  these  situations, 
is  most  prone  to  be  confounded  with  it.  A  distinction  can  be 
made  by  noting  the  ready  manner  in  which  a  clot  can  be  broken 
up  by  the  pressure  of  the  fingers,  while  a  portion  of  placenta 
cannot.  If  the  cervical  canal  is  closed,  the  placenta  can  be  felt 
as  a  thick  and  soft  mass  lying  between  the  uterine  wall  and  the 
presenting  part  at  one  or  other  side.     The  cervix  and  the  lower 


THE  TREATMENT  OF  PLACENTA   PR  Ail'  I A 


697 


uterine  segment  are  also  softer  than  normal,  and  the  vessels  of  the 
lateral  fornix  are  enlarged  and  pulsate  more  strongly  than  normal. 
If  the  placenta  cannot  be  felt,  the  case  is  to  be  treated  as  one  of 
accidental  haemorrhage. 

A  placenta  prsevia  may  also  be  sometimes  diagnosed  by  ab- 
dominal palpation.  This  can  be  done  by  noticing  that  there  is 
something  which  either  displaces  the  presenting  part  to  one  or 
other  side  of  the  false    pelvis,  or  prevents  it   from  descending 


Fig.   300 — A  Marginal  Placenta  Pr.lvia.     (Ahlfeld.) 


through  the  brim.  Then,  on  very  careful  palpation,  a  soft  mass 
may  be  felt  at  the  side  from  which  the  presenting  part  has  been 
displaced.  If  the  presenting  part  is  fixed  in  the  brim,  it  is  almost 
certain  that  the  case  is  not  one  of  placenta  praevia. 

Treatment. — The  first  point  to  recognise  with  regard  to  the 
treatment  of  placenta  praevia  is  that,  immediately  the  condition 
is  diagnosed,  steps  must  be  taken  with  a  view  to  ending  the 
pregnancy,  whether  the  bleeding  has  temporarily  ceased  or  not. 


698  THE  PATHOLOGY  OF  PREGNANCY 

The  only  exception  which  may  be  made  to  this  rule,  is  in  those 
cases  in  which  the  patient  is  in  such  circumstances  that,  if  the 
bleeding  restarts,  she  can  be  immediately  treated.  Many  cases 
have  been  lost  because,  on  the  arrival  of  the  medical  man,  the 
bleeding  was  found  to  have  ceased,  and  so  treatment  was  not 
adopted,  with  the  result  that  the  bleeding  recurred  with  fatal 
consequences. 

As  in  accidental  haemorrhage,  the  line  of  treatment  to  be 
adopted  depends  to  a  very  great  extent  upon  whether  the  patient 
is  in  labour  or  not.  If  she  is  in  labour,  the  treatment  of  the  case 
is  comparatively  simple,  both  because  uterine  contractions  are 
present,  and  also  because  the  fact  that  haemorrhage  did  not  occur 
until  the  patient  came  into  labour,  shows  that  the  placenta  is  not 
very  close  to  the  os. 

Again,  as  in  accidental  haemorrhage,  the  objects  of  our  treat- 
ment are  to  check  the  bleeding  and  to  bring  on  labour  gradually. 
These  objects  are  best  attained  by  the  method  introduced  by 
Braxton  Hicks.-  This  consists  in  turning  the  child  by  podalic 
version  into  a  breech  presentation,  in  rupturing  the  membranes, 
and  in  drawing  down  a  foot.  The  remainder  of  the  expulsion 
of  the  foetus  is  then  left  to  Nature.  The  result  of  this  treatment 
is  that  the  haemorrhage  is  checked  by  the  pressure  of  the 
breech  and  subsequently  of  the  body  of  the  child  upon  the 
placenta,  while  the  rupture  of  the  membranes  and  the  partial 
extraction  of  the  foetus  ensure  the  onset  of  labour.  If  there  is 
any  return  of  the  bleeding,  a  little  traction  on  the  foot  will  drag 
down  more  of  the  breech,  and  so  increase  the  pressure  upon 
the  placenta.  If,  as  may  happen  in  very  rare  cases,  labour  pains 
do  not  come  on  within  twelve  hours,  or  if,  before  that  time 
— the  foetus  being  dead,  signs  of  decomposition  set  in,  delivery 
must  be  accomplished  by  means  of  gentle  traction  upon  the  foot. 
The  method  of  performing  bi-polar  version,  which  the  author 
prefers,  differs  somewhat  from  the  more  classical  method  of 
Braxton  Hicks,  and  will  be  described  in  its  proper  place. 

In  order  that  this  line  of  treatment  may  be  carried  out  satis- 
factorily, two  conditions  must  be  fulfilled : — 

(1)  The  cervical  canal  must  be  of  sufficient  size  to  admit  at 
least  two  fingers.  If  the  haemorrhage  is  at  all  severe,  this  con- 
dition is  practically  always  fulfilled. 

(2)  The  membranes  must  be  intact,  or  only  quite  recently 
ruptured.  If  the  uterus  has  become  contracted  down  upon  the 
foetus  it  will  be  found  impossible  to  turn  except  by  internal 
version,  and  there  is  rarely  or  never  sufficient  cervical  dilatation 
to  allow  of  this.  This  condition  will  also  be  always  fulfilled 
unless  an  ignorant  attendant  has  ruptured  the  membranes. 

In  the  rare  cases  in  which  the  cervical  canal  is  not  sufficiently 
dilated  to  admit  two  fingers,  and  in  which  the  haemorrhage  is  so 

*  'The  Treatment  of  Placenta  Praevia,'  Medical  Press  and  Circular,  Sep- 
tember 9,  1885,  p.  223  ;  and  Brit.  Med.  Journ.,  November  30,  1889,  p.  1205. 


THE  TREATMENT  OF  PLACENTA  PRJEVIA  699 

severe  that  it  is  impossible  to  wait  for  a  short  time  to  allow  it  to 
dilate,  the  firm  plugging  of  the  vagina  with  iodoform  gauze  and 
cotton-wool  is  indicated,  as  in  accidental  haemorrhage. 

When  the  patient  is  in  labour,  the  treatment  of  the  case  is 
the  same  as  that  of  accidental  haemorrhage  occurring  under  the 
same  conditions.  Commence  by  rupturing  the  membranes,  a 
proceeding  which  is  usually  sufficient.  This  acts  by  allowing 
the  head  to  advance  without  causing  traction  through  the  mem- 
branes upon  the  placenta,  and  at  the  same  time  the  descending 
head  presses  upon  the  placenta  and  checks  haemorrhage,  as  does 
the  breech  after  version  has  been  performed.  If  this  is  not 
sufficient  to  check  the  bleeding,  internal  version  may  be  per- 
formed, followed  or  not  by  extraction,  according  to  the  patient's 
condition  and  the  size  of  the  os.  If  the  head  is  fixed  and  the  os 
sufficiently  dilated,  the  forceps  may  be  applied. 

Other  Modes  of  Treatment. — The  foregoing  is  the  treatment 
which  we  consider  most  suitable.  Other  lines  of  treatment  have 
been  recommended  by  various  authorities,  and  of  these  the 
following  are  the  chief  : — ■ 

(1)  Champetier  de  Ribes'  Bag.— The  plugging  of  the  lower 
uterine  segment  by  means  of  a  Champetier  de  Ribes'  bag  is 
perhaps  the  line  of  treatment  which,  after  bi-polar  version,  has 
the  greatest  number  of  advocates  at  the  present  day.  A  Cham- 
petier de  Ribes'  bag  is  a  pear-shaped  bag  made  of  waterproofed 
silk.  Its  wide  end  or  base  is  three  and  a  half  inches  across,  while 
the  narrow  end  tapers  to  join  a  half-inch  rubber  tube,  with  which 
it  is  continuous,  and  by  which  it  is  filled.  The  manner  in  which 
the  bag  is  introduced  will  be  subsequently  described.  Care  must 
be  taken  that  it  lies  completely  above  the  placenta.  In  order  that 
it  may  press  against  the  latter  with  the  necessary  force,  it  is 
connected  with  the  foot  of  the  bed  by  means  of  an  elastic  cord, 
which  is  made  as  tight  as  the  patient  can  bear.  The  effect  of  the 
introduction  into  the  amniotic  cavity  of  a  pear-shaped  bag,  like  that 
of  Champetier  de  Ribes,  is  to  cause  a  compression  of  the  placenta 
against  the  uterine  wall,  and  at  the  same  time  a  dilatation  of  the 
cervical  canal,  in  very  much  the  same  manner  as  the  breech  of 
the  child  does  in  Braxton  Hicks'  method ;  while  the  rupture  of 
the  membranes  also  helps  to  bring  on  uterine  contractions.  The 
bag  is  allowed  to  remain  in  the  uterus  as  long  as  it  will — that  is, 
until  the  cervical  canal  is  so  dilated  that  it  slips  out.  If  this 
does  not  happen  within  twelve  hours  the  bag  must  be  removed, 
the  child  turned  by  bi-polar  or  internal  version,  according  to  the 
size  of  the  os,  and  extracted  immediately  or  not,  according  to  the 
condition  of  the  patient.  The  average  time  which  the  bag  takes 
to  dilate  the  cervix  is  said  to  be  five  hours  and  ten  minutes 
(Blacker).  In  the  case  of  a  central  placenta  praevia,  the  bag 
must  be  introduced  through  an  opening  in  the  placenta  made 
over  the  inner  os. 

The   advantages   claimed   for  this   course   of  procedure  over 


7oo  THE  PATHOLOGY  OF  PREGNANCY 

Braxton  Hicks'  method  are  the  ease  with  which  it  can  be  carried 
out,  and  the  improved  fetal  prognosis.  While  fully  recognising 
it  as  a  perfectly  scientific  mode  of  treatment,  and  one  which 
gives  excellent  results,  the  writer  considers  it  to  be  inferior,  for 
general  use,  to  version.  In  careless  hands  it  is  more  liable  to 
cause  sepsis,  inasmuch  as  a  possibly  non-sterile  foreign  body  is 
lying  for  some  hours  in  the  uterus ;  and  its  performance,  which 
may  not  be  required  very  frequently,  necessitates  the  use  of  a 
special  apparatus,  and  one,  moreover,  which  is  very  liable  to  be 
destroyed  by  keeping. 

(2)  Accouchement  Force. — The  adoption  of  accouchement  force  is 
even  more  dangerous  in  the  case  of  placenta  praevia  than  it  is  in 
the  case  of  accidental  haemorrhage,  owing  to  the  softened  and 
vascular  condition  of  the  cervix,  and  the  consequent  risk  of 
laceration.  It  is  essential  to  remember  that  in  these  cases  no 
attempt  may  be  made  to  deliver  the  foetus  through  an  incom- 
pletely dilated  os. 

(3)  Plugging  of  the  Vagina. — Plugging  of  the  vagina  is  an 
objectionable  and  unnecessary  course  of  procedure  in  placenta 
praevia.  There  is  always  some  risk  of  sepsis  following  the  use 
of  a  plug,  and  this  risk  is  very  much  increased  in  those  cases  in 
which  the  placenta  is  situated  in  the  lower  uterine  segment,  as 
the  inoculation  of  the  placental  site  by  the  extension  of  vaginal 
infection  is  so  easy.  Further,  we  have  .an  excellent  and  safe 
mode  of  treating  these  cases  which  we  do  not  possess  in  the  case 
of  accidental  haemorrhage,  viz.,  version.  Accordingly,  the  use  of 
the  plug  should  be  limited  to  the  small  proportion  of  cases  in 
which  it  is  absolutely  necessary,  viz.,  to  those  cases  in  which 
the  patient  is  bleeding,  and  in  which  the  cervical  canal  is  not 
sufficiently  dilated  to  admit  even  two  fingers. 

(4)  Partial  Detachment  of  the  Placenta. — Detachment  of  the 
placenta  from  the  lower  uterine  segment  is  the  main  feature 
of  the  treatment  recommended  by  Barnes.*  The  steps  of  his 
procedure,  in  his  own  words,  are  as  follows  : — 

'  (a)  Rupture  the  membranes  ;  this  disposes  the  uterus  to 
contract. 

'  (b)  Apply  a  firm  bandage  over  the  abdomen. 

'  (c)  A  tampon  may  be  introduced  to  gain  time,  but  it  is  not 
necessary  to  do  so.     Watch  ;  observe  with  vigilance. 

'  (d)  Detach  all  the  placenta  adhering  within  the  inferior  zone, 
and  always  watch.  If  there  is  no  haemorrhage,  wait  a  little.  The 
uterus  may  perhaps  do  what  is  necessary.  If  this  fails,  dilate  the 
cervix  with  the  hydrostatic  dilator.  Wait  and  watch.  If  the 
natural  forces  fail,  employ  the  forceps,  which  gives  the  best 
chance  to  the  child,  or,  as  a  last  resort,  perform  version. 

'  (e)  Avoid  as  far  as  possible  everything  that  predisposes  to 
septicaemia.' 

Barnes'  treatment  has  now  but  very  few  supporters.  At  the 
*  '  Obstetric  Operations.' 


THE  COMPLICATIONS  OF  PLACENTA  PRMVIA  701 

time  at  which  it  was  introduced  it  was  a  considerable  advance 
over  the  methods  in  use,  inasmuch  as  it  prevented  the  rapid 
emptying  of  the  uterus.  It  is,  however,  very  much  inferior  to 
either  Braxton  Hicks'  method  or  to  the  use  of  Champetier  de 
Ribes'  bag.  It  is  a  very  tedious  course  of  procedure  for  the 
patient,  and  one  which  affords  many  opportunities  of  inoculating 
her  with  septic  organisms.  In  placenta  prsevia,  more  than  in 
any  other  condition,  the  number  of  vaginal  examinations  must 
be  brought  down  as  near  the  irreducible  minimum  as  possible, 
on  account  of  the  ease  of  infecting  the  placental  site.  But 
Barnes'  method  demands  repeated  examinations  in  order  to  carry 
out  its  multiple  steps,  and  to  ensure  that  the  necessary  'vigilance' 
is  being  used. 

Complications. — Although  the  main  danger  caused  by  placenta 
praevia  is  death  from  haemorrhage  coming  from  the  placental  site, 
there  are  still  other  grave  risks  sufficiently  imminent  to  require 
careful  consideration  during  the  treatment  of  a  case.  Of  these 
the  following  are  the  chief: — ■ 

(1)  Laceration  of  the  Cervix. — As  has  been  already  mentioned, 
laceration  of  the  cervix  is  very  prone  to  occur  in  these  cases, 
owing  to  the  softened  condition  of  the  cervix  resulting  from  its 
increased  blood-supply.  Further,  for  the  same  reason,  lacerations 
are  most  dangerous,  as,  if  any  of  the  large  vessels  going  to 
the  placenta  are  torn  across,  fatal  traumatic  haemorrhage  will 
very  probably  result.  It  is  this  which  in  these  cases  makes 
accouchement  force  so  dangerous  a  proceeding,  and  which  furnishes 
a  direct  contra-indication  to  the  extraction  of  the  child  through  an 
incompletely  dilated  cervix.  If  post-partum  haemorrhage  occurs, 
the  possibility  of  its  being  due  to  a  cervical  laceration  must  always 
be  borne  in  mind. 

(2)  Septic  Infection. — In  consequence  of  the  proximity  of  the 
placental  site  to  the  vagina,  the  absorption  of  septic  organisms, 
or  of  ptomaines,  may  very  easily  take  place.  Such  absorption 
may  occur  not  only  during  labour,  but  also  during  the  puer- 
perium.  Accordingly,  as  has  been  already  said,  vaginal  examina- 
tions must  be  avoided  as  far  as  possible  during  labour,  and  any 
appearance  of  sapramic  change  in  the  vaginal  contents  after 
confinement  must  be  immediately  treated. 

(3)  Post-partum  Haemorrhage. — Postpartum  haemorrhage  in 
cases  of  placenta  praevia  is  a  comparatively  common  occurrence. 
Its  frequency  is  due  to  three  factors  : — 

(a)  Laceration  of  the  Cervix. — This  has  been  already  noted. 

(b)  The  Situation  of  the  Placental  Site. — When  a  large  portion 
of  the  placenta  extends  below  the  contraction  ring,  the  placental 
site  cannot  be  affected  to  the  same  extent  by  the  subsequent  con- 
traction and  retraction  of  the  uterine  muscle  as  if  the  placenta 
was  entirely  situated  in  the  contractile  part  of  the  uterus.  As  a 
result,  the  lumen  of  the  placental  vessels  may  not  be  completely 
obliterated. 


702  THE  PATHOLOGY  OF  PREGNANCY 

(c)  The  Debilitating  Effect  of  Previous  Haemorrhage  upon  the 
Patient. — Marked  anaemia  and  debility,  the  results  of  previous 
haemorrhages,  have  frequently  a  very  prejudicial  effect  upon  the 
uterine  contractions. 

Prognosis.- — The  prognosis  in  placenta  praevia  depends  greatly 
upon  the  treatment  adopted.  The  maternal  mortality  is  said  to 
vary  between  two  and  forty  per  cent.  Galabin  had  ninety-two 
cases,  with  eight  deaths  ;  Winckel,  nineteen  cases,  with  one  death  ; 
Diihrssen,  fifty  cases,  with  two  deaths.  Blacker  has  collected 
twenty-two  cases,  in  which  the  Champetier  de  Ribes'  bag  was 
used,  with  one  death.  At  the  Rotunda  Hospital,  where  Braxton 
Hicks'  method  is  used  in  all  severe  cases,  108  cases  were  treated 
from  November,  1889,  to  November,  1903,  with  three  deaths. 
Of  these  deaths,  one  was  due  to  rupture  of  the  uterus  occurring 
in  a  case  in  which  the  forceps  was  applied.  A  second  was  due 
to  haemorrhage,  the  patient  being  admitted  moribund  after  a 
journey  of  five  miles  in  an  open  cart.  The  third  died  of  sapraemia, 
from  which  the  patient  was  suffering  when  admitted.  As  in 
accidental  haemorrhage,  the  foetal  mortality  is  very  high — from 
40  to  60  per  cent.. 

Foetal  Mortality  in  Accidental  and  Unavoidable  Haemorrhage. — 
A  few  words  must  be  said  with  regard  to  the  foetal  mortality  in 
these  cases.  It  has  been  found  by  experience  that,  in  ante- 
partum haemorrhage,  the  life  of  the  child  is  more  or  less 
antagonistic  to  the  life  of  the  mother,  and  that  any  treatment 
which  will  give  the  lowest  maternal  mortality  will  give  the 
highest  foetal  mortality,  and  vice- versa.  Accouchement  force,  which 
in  the  past  gave  a  maternal  mortality  of  from  40  to  60  per  cent., 
gave  a  considerably  lower  foetal  mortality  than  does  the  treatment 
which  is  adopted  at  the  present  day.  So  far,  no  treatment  has 
been  described  which  materially  reduces  the  foetal  mortality, 
while  affording  the  same  excellent  maternal  results  that  are 
obtained  by  Braxton  Hicks'  treatment  in  placenta  praevia,  or  by 
vaginal  plugging  in  accidental  haemorrhage.  This  condition  of 
affairs  is,  after  all,  what  must  be  expected.  So  far  as  we  can 
see  at  present,  it  is  necessary  to  give  the  mother  as  much  time  as 
possible  to  recover  from  the  haemorrhage  which  has  occurred, 
before  the  uterus  is  emptied  either  naturally  or  artificially. 
During  this  time,  the  supply  of  oxygen  to  the  foetus  is  limited  to 
that  amount  which  can  come  through  a  placenta,  of  which  not 
only  a  large  portion  is  detached,  but  of  which  the  remainder  is 
undergoing  a  more  or  less  forcible  compression  against  the  uterine 
wall.  If  this  compression  can  obliterate  the  vessels  which  are 
torn  across,  it  must  also  to  some  extent  diminish  the  size  of  the 
lumen  of  those  which  are  intact.  Furthermore,  even  if  the  foetus 
is  delivered  alive,  its  expectation  of  life  is  extremely  bad.  It  is 
frequently  premature,  and  has  always  suffered  more  or  less  from 
deprivation  of  oxygen.  As  a  result,  such  infants  very  frequently 
die  during  the  first  month  after  birth.     It  may  frequently  appear, 


HEMORRHAGES,  INDEPENDENT  OF  PREGNANCY  703 

in  cases  of  placenta  praevia,  as  if  slight  traction  upon  the  leg 
of  the  child  would  save  its  life  by  hastening  its  delivery,  and  the 
very  natural  desire  to  save  both  lives  may  induce  us  to  do  so. 
In  some  cases,  where  the  condition  of  the  mother  is  good  and  the 
cervix  is  sufficiently  dilated  to  remove  the  danger  of  laceration, 
it  may  be  possible  to  hasten  delivery  without  increasing  the 
maternal  danger  to  an  unjustifiable  extent.  On  the  other  hand,  if 
the  case  is  one  which  should  have  been  left  to  Nature — as  the 
majority  are,  we  may  find  that  we  have  sacrificed  the  life  of  the 
mother  for  the  sake  of  an  infant  who  succumbs  shortly  after  its 
birth. 


HEMORRHAGES  OCCURRING  INDEPENDENTLY 
OF  PREGNANCY 

Menstruation. 

The  possibility  of  menstruation  occurring  during  pregnancy 
is  a  question  which  apparently  has  not  been  definitely  answered. 
In  answering  it,  much  depends  upon  the  meaning  we  attach  to 
the  word  '  menstruation.'  If  the  latter  is  understood  to  mean 
merely  a  periodical  discharge,  there  is  apparently  no  reason 
why  it  should  not  occur.  Undoubtedly,  the  uterus  undergoes 
some  form  of  stimulation,  even  during  pregnancy,  at  what 
would  have  been  menstrual  periods  if  the  patient  had  not  been 
pregnant.  Under  such  circumstances,  it  is  not  very  difficult  to 
believe  that  the  attendant  congestion  may  cause  a  slight  haemor- 
rhagic  discharge  from  an  ulcerated  cervix,  a  polypus,  or  even 
from  the  inflamed  decidua  vera  covering  the  lower  pole  of  the 
uterus  before  this  membrane  has  come  into  contact  with  the 
decidua  reflexa  — that  is,  before  the  third  month.  If,  however, 
we  more  correctly  limit  the  term  to  the  physiological  discharge 
which  accompanies  the  monthly  destruction  and  expulsion  of  the 
uterine  endometrium,  it  is  obviously  impossible  that  menstruation 
could  take  place  during  pregnancy  without  causing  abortion.  Cases 
of  supposed  menstruation  during  pregnancy  can  almost  invariably 
be  accounted  for  by  some  pathological  condition  of  the  uterus  or 
cervix.  The  regular  recurrence  of  a  monthly  discharge  during 
the  entire  period  of  pregnancy  almost  invariably  points  to  the 
existence  of  a  double  uterus.  Pajot  said  that,  while  the  haemor- 
rhagic  discharges  which  occur  during  pregnancy  may  have  some 
characters  which  cause  them  to  resemble  menstruation,  they 
invariably  differ  from  the  latter  in  their  duration,  and  in  the 
quantity  and  quality  of  the  blood.  Pinard  stated  that  a  case  of  the 
persistence  of  menstruation  in  a  pregnant  woman  had  never  yet 
been  observed.  Dakin  considers  that,  '  while  one  monthly  bleeding 
may  be  allowed  to  pass  as  a  menstruation  in  the  absence  of  any 
discoverable  cause,  or  of  any  further  disturbance,  any  repetition  of 


704  THE  PATHOLOGY  OF  PREGNANCY 

this  should  always  be  looked  upon  as  a  threatening  of  abortion, 
and  the  patient  treated  on  this  assumption.' 

American  writers,  on  the  other  hand,  do  not  regard  the  per- 
sistence of  menstruation  as  so  improbable  or  impossible.  Lusk 
considered  that  the  occurrence  of  pregnancy  is  not  incompatible 
with  the  existence  of  a  periodical  flow — to  which,  however,  he  is 
careful  not  to  apply  the  term  '  menstruation.'  Parvin  stated  that 
a  monthly  flow  may  occur  once  or  oftener  during  pregnancy,  or 
even  recur  during  the  whole  period.  While  Palmer  of  Ohio 
records  the  case  of  a  patient  of  his  own  who  never  menstruated 
except  when  she  was  pregnant ! 

The  general  attitude  of  modern  obstetricians,  in  the  case  of 
patients  who  consider  themselves  to  be  pregnant  while  they  are 
still  menstruating,  may  be  summed  up  in  the  words  of  Stoltz  : — 
'  Rarely  will  one  be  deceived  who  regards  a  woman  menstruating 
regularly,  with  all  the  characters  of  menstruation,  as  not  pregnant; 
while  trusting  the  contrary  opinion,  he  is  exposed  to  frequent 
errors.' 

HAEMORRHAGE    FROM    TUMOURS. 

Myomata  of  the  uterus  often  cause  sterility,  and  consequently 
are  not  a  very  frequent  complication  of  pregnancy.  Intra- uterine 
myomata  may,  during  pregnancy  or  labour,  give  rise  to  accidental 
haemorrhage  by  causing  the  detachment  of  the  placenta,  owing  to 
the  irregularity  their  presence  imparts  to  the  uterine  contractions. 
Subsequent  to  delivery,  they  are  a  very  common  cause  of  post- 
partum haemorrhage.  Myomata  of  the  cervix,  or  pedunculated 
myomata  of  the  uterus  which  project  into  the  vagina,  may  give 
rise  to  constant  small  haemorrhages  during  pregnancy,  and  have 
been  found  as  the  cause  of  periodical  discharges  which  have 
simulated  menstruation. 

Malignant  disease  of  the  cervix  or  vagina  usually  causes  a  more 
or  less  continuous  hsemorrhagic,  and  perhaps  sanious,  discharge 
during  the  whole  of  pregnancy.  It  will  also  favour  the  occur- 
rence of  abortion  owing  to  the  anaemia  and  cachexia  it  induces. 

Other  tumours  or  pathological  conditions,  whose  existence  may 
give  rise  to  slight  haemorrhage  coming  from  the  vagina  or  its 
neighbourhood  during  pregnancy,  are  urethral  caruncle,  mucous 
polypi  of  the  cervix,  and  haemorrhoids. 

HEMORRHAGE    FROM    TRAUMATISMS. 

Traumatisms  in  the  region  of  the  vagina  and  vulva  may  cause 
a  varying  degree  of  haemorrhage,  according  to  the  nature  of  the 
lesion,  but  considerably  more  interesting  than  the  immediate  effect 
of  such  injuries  is  the  question  of  the  result  of  a  traumatism, 
either  surgical  or  otherwise,  upon  the  pregnancy.  So  far,  the  most 
varying  consequences  have  been  met  with.  In  some  women,  a 
very  severe  accident  or  surgical  operation  has  been  attended  by  no 
bad  effects  upon  the  pregnancy.     In  other  women,  the  slightest 


THE  EFFECT  OF  TRAUMATISMS  ON  PREGNANCY  705 

accident  or  interference  has  been  followed  by  the  immediate 
emptying  of  the  uterus.  Gueniot's  conclusions  on  this  subject  are 
as  follows  : — 

(1)  The  harm  wrought  by  traumatism  occurring  during  preg- 
nancy is  not  governed  by  any  absolute  law. 

(2)  If  the  woman  is  without  morbid  predisposition — she,  her 
uterus,  and  the  ovum  healthy,  a  traumatism  is  generally  without 
injurious  effect  upon  the  pregnancy. 

(3)  If  gestation  is  complicated  by  a  pathological  condition,  such 
as  abnormal  irritability  of  the  uterus,  disease  or  great  size  jof  the 
ovum,  albuminuria,  etc.,  the  traumatism,  however  slight,  and 
whatever  the  part  involved,  may  frequently  cause  the  premature 
expulsion  of  the  ovum. 

(4)  Great  caution  is  necessary  in  performing  surgical  operations 
during  pregnancy. 

Ribemont-Dessaignes*  considers  that  accidental  traumata  vary 
in  their  effects,  according  to  their  intensity,  their  site,  the  amount 
of  haemorrhage  which  accompanies  them,  and  the  occurrence  of 
wound  complication,  sepsis,  etc.  As  regards  surgical  intervention, 
Verneuil  says  : — '  Surgical  intervention  is  not  forbidden  during 
pregnancy,  but  is  under  the  guidance  of  a  definite  rule — to  abstain 
from  it  when  it  is  possible  to  do  so ;  to  intervene  when  it  is 
necessary.' 

*   '  Precis  d'Obstetrique,'  3rd  edition,  p.  690. 


45 


PART  VII 
THE    PATHOLOGY    OF    LABOUR 


45—2 


CHAPTER  I 
ANOMALIES  OF  THE  EXPELLING  FORCES 

Precipitate  Labour — ^Etiology — Symptoms — Treatment.  Uterine  Inertia — 
Primary  Inertia — Secondary  Inertia.  Spasmodic  and  Irregular  Uterine 
Contractions  — Spasmodic  Contraction  of  the  Body — Spasmodic  Con- 
traction of  the  Cervix. 

The  uterine  contractions  of  labour  may  present  three  variations 
from  the  normal : — They  may  be  too  strong  in  proportion  to  the 
resistance  offered  to  the  descent  of  the  foetus  ;  they  may  be  too 
weak  ;  or  they  may  be  abnormal  in  their  mode  of  occurrence. 
Accordingly,  we  shall  consider  the  anomalies  of  the  expelling 
forces  under  three  heads  : — 

I.  Precipitate  labour. 
II.   Uterine  inertia. 
III.  Continuous  and  irregular  uterine  contractions. 

PRECIPITATE  LABOUR 

Precipitate  labour  is  the  term  applied  to  the  too  rapid  expulsion 
of  the  foetus. 

Aitiology. — The  cause  of  precipitate  labour,  stated  in  general 
terms,  is  a  disproportion  between  the  strength  of  the  uterine  con- 
tractions and  the  resistance  offered  to  the  descent  of  the  foetus. 
Accordingly,  excessively  strong  uterine  contractions,  a  small 
foetus,  or  an  easily  dilatable  parturient  canal,  may  cause  its  occur- 
rence. The  cause  of  abnormally  strong  uterine  contractions  is 
obscure.  It  may  be  found  in  an  undue  development  of  the 
uterine  muscle  fibres,  in  an  unusually  excitable  condition  of  the 
uterine  nerve  centres,  or  in  the  application  of  unusually  strong 
stimuli  to  these  centres.  Excessive  muscular  development  of  the 
uterus  may  account  for  those  cases  of  hereditary  tendency  to  pre- 
cipitate labour,  which  have  been  recorded  from  time  to  time.  An 
unusually  irritable  condition  of  the  nerve  endings  may  be  the 
result  of  previous  inflammatory  conditions  of  the  uterus.  Un- 
usually strong  stimulation  of  the  nerve  centres  may  occur  in 
certain  mental  conditions,  such  as  extreme  fright,  or  may  be  the 

709 


7io  THE  PATHOLOGY  OF  LABOUR 

result  of  some  substance  which  acts  as  an  oxytocic.  Excess  of 
C02  in  the  blood  normally  acts  as  a  stimulus  to  uterine  action, 
and,  if  the  excess  is  considerable,  the  action  of  the  uterus  may  be 
proportionately  stronger  than  normal.  Cases  of  maternal  asphyxia 
have  been  recorded,  in  which  death  must  have  occurred  rapidly, 
but  in  which  delivery  apparently  took  place  during  the  period 
of  asphyxia,  a  fact  which  points  to  the  occurrence  of  unusually 
strong  uterine  contractions.  In  acute  infectious  diseases,  pre- 
cipitate labour  also  occurs,  and  here,  again,  some  toxic  condition 
of  the  blood  may  furnish  the  additional  stimulus. 

According  to  Winckel,*  the  chief  predisposing  causes  of  pre- 
cipitate labour  are  to  be  found  in  multiple  pregnancy,  diseased 
condition  of  the  patient  (syphilis,  bronchitis,  epilepsy),  small  size 
and  maceration  of  the  foetus,  and  shortness  of  the  umbilical  cord. 
Symptoms. — When  precipitate  labour  is  due  to  unduly  strong 
uterine  contractions,  the  latter  may  follow  one  another  so  rapidly 
as  to  be  almost  continuous.  They  may  be  present  from  the 
commencement  of  labour,  or  may  not  occur  until  towards  the 
end  of  the  first  stage.  If  the  birth  canal  is  dilatable,  the  foetus  is 
rapidly  expelled,  and  may  be  shot  out  some  little  distance  from  the 
vulvar  orifice.  In  such  cases,  the  cord  may  be  torn,  or  even 
detachment  of  the  placenta  may  result  from  the  sudden  drag 
upon  it.  Such  accidents  are  especially  liable  to  occur,  if  the 
patient  happens  to  be  in  a  standing  position  when  delivery  takes 
place.  If  the  birth  canal  is  not  easily  dilatable,  extreme  degrees  of 
laceration  of  the  cervix,  vagina,  or  perinaeum  may  readily  result. 
Another  complication  is  post-partum  haemorrhage,  due,  in  all 
'probability,  to  the  fact  that,  owing  to  the  short  duration  of 
labour,  the  normal  degree  of  retraction  of  the  uterine  fibre  has 
not  occurred,  and  that,  consequently,  the  usual  mechanism  by 
which  haemorrhage  is  checked  fails. 

Treatment. — It  will  be  seen  from  the  foregoing  that  precipitate 
labour  is  by  no  means  free  from  danger,  so  far  as  the  mother  and 
the  foetus  are  concerned.  The  principal  danger  to  the  former 
consists  in  laceration  of  the  parturient  canal  and  in  post-partum 
haemorrhage,  and  to  the  latter  in  its  birth  when  the  mother  is  in 
an  unsuitable  position,  with  perhaps  consequent  rupture  of  the  cord 
and  umbilical  haemorrhage.  Unfortunately,  however,  our  know- 
ledge of  the  occurrence  of  precipitate  labour  is  usually  post  facto, 
and  only  serves  to  warn  us  of  what  may  happen  on  a  subsequent 
occasion.  If  a  patient  is  known  to  be  the  subject  of  too  rapid 
labours,  she  must  lie  down  as  soon  as  the  warning  symptoms 
of  labour  occur,  and  must  not  be  allowed  to  get  up,  especially 
for  the  purpose  of  going  to  stool,  as  accidents  have  frequently 
occurred  in  this  way.  If  the  medical  attendant  is  present,  chloro- 
form should  be  administered  as  soon  as  the  contractions  become 
unduly  violent.  The  third  stage  should  never  be  hastened,  as 
incomplete  retraction  of  the  uterine  muscle  is  usually  present. 

*  Op.  cit.,  p.  517. 


PRIMARY  UTERINE  INERTIA  711 

UTERINE  INERTIA. 

Uterine  inertia  is  the  term  applied  to  the  occurrence  of  weak 
labour  pains.  It  may  occur  as  a  primary  condition,  present  from 
the  commencement  of  labour,  or  as  a  secondary  condition,  which 
does  not  occur  until  the  end  of  the  first  or  during  the  second 
stage.  As  primary  inertia  differs  from  secondary  inertia,  both  in 
its  causes  and  treatment,  we  shall  discuss  the  two  conditions 
separately. 

Primary  Uterine  Inertia. — Primary  uterine  inertia,  as  has 
been  mentioned,  is  present  from  the  beginning  of  labour,  and  the 
uterus  never  contracts  with  the  normal  strength.  It  is  a  rarer 
condition  than  secondary  uterine  inertia,  as  will  be  understood 
when  its  aetiology  is  taken  into  consideration. 

^Etiology. — Primary  inertia  is  usually  due  to  faulty  development 
of  the  uterus,  resulting  in  imperfect  muscular  development ;  to 
changes  in  the  uterine  tissue,  the  result  of  disease  or  of  too 
frequent  pregnancies  ;  to  faulty  uterine  innervation ;  or  to  a  de- 
bilitated condition  of  the  patient.  In  uterus  unicornis,  or  bicornis, 
in  uterus  septa,  and  in  persistence  of  an  infantile  type  of  uterus, 
muscular  development  is,  as  a  rule,  incomplete,  and,  consequently, 
the  muscular  force  necessary  to  provide  contractions  of  the 
required  strength  is  lacking.  The  same  condition  may  also 
result  in  consequence  of  the  presence  of  tumours  of  the  uterus 
such  as  myomata,  or  from  alterations  in  the  muscle  fibre,  the  result 
of  inflammation  or  overdistension.  Faulty  innervation  of  the 
uterus  must  be  a  very  rare  occurrence,  and  when  present  would 
most  probably  result  in  missed  labour.  Primary  inertia,  the  result 
of  a  debilitated  condition  of  the  patient,  may  occur  after  severe 
ante-partum  haemorrhages,  chlorosis,  anaemia,  phthisis,  and  such 
conditions. 

Symptoms. — The  symptoms  of  primary  inertia  are  obvious,  and 
are  present  from  the  commencement  of  labour.  The  intervals 
between  the  contractions  are  prolonged,  the  contractions  them- 
selves are  short,  and  cause  but  slight  hardening  of  the  uterus  and 
a  correspondingly  slight  degree  of  pain.  Dilatation  of  the  cervix 
proceeds  slowly  and  is  often  incomplete,  and  the  second  and  third 
stages  are  similarly  prolonged.  In  the  third  stage,  severe  haemor- 
rhage may  follow  the  detachment  of  the  placenta.  The  condition  of 
the  patient  is  at  first  unaffected  by  the  delay,  as,  owing  to  the 
absence  of  strong  contractions,  there  is  no  undue  pressure  upon  the 
soft  parts.  In  some  cases,  the  pains  may  pass  off  completely,  and 
a  condition  of  missed  labour  result.  In  other  cases,  however,  the 
contractions  may  be  sufficiently  strong  to  drive  the  head  into  the 
pelvis,  and  its  prolonged  presence  there  may  cause  severe  com- 
pression of  the  soft  parts,  with  resultant  cramp-like  pains  and 
swelling  and   cedema  of  the  legs  and  vulva.     The  temperature 


712  THE  PATHOLOGY  OF  LABOUR 

rises  in  consequence  of  decomposition  of  the  liquor  amnii  in  the 
vagina,  and  there  is  a  corresponding  rise  in  the  rate  of  the  pulse. 
The  patient  becomes  restless  and  weak,  and  death  results  if  she  is 
allowed  to  remain  undelivered.  During  the  puerperium,  fistulae 
may  form  between  the  bladder  or  rectum  and  the  vagina,  in  con- 
sequence of  sloughing  of  the  tissues  from  the  prolonged  pressure. 

Diagnosis. — -The  diagnosis  of  primary  inertia  is  made  from  the 
foregoing  symptoms,  and  especially  by  noting  that  the  consistency 
of  the  uterus  changes  but  slightly  during  a  pain.  The  rate  of 
advance  of  the  presenting  part  is  not  a  reliable  sign,  as  it  may  be 
retarded  from  many  causes  other  than  inertia. 

Treatment. — It  is  important  to  distinguish  between  primary  and 
secondary  inertia,  owing  to  the  difference  in  the  treatment  of  the 
two  conditions.  In  secondary  inertia,  it  frequently  is  possible  to 
cause  a  return  of  the  contractions  by  the  adoption  of  suitable 
treatment,  while  in  true  primary  inertia  it  rarely  is  possible  to 
stimulate  contractions.  It  is  always  advisable  to  wait  for  con- 
tractions, if  there  is  any  prospect  of  their  occurring,  as  they 
lessen  the  risk  of  post-partum  haemorrhage.  If,  however,  there 
is  no  prospect  of  such  return,  there  is  nothing  to  be  gained  by 
allowing  the  patient  to  remain  undelivered.  For  these  reasons, 
the  treatment  of  primary  inertia  consists  in  stimulating,  as  far  as 
possible,  the  contractions  that  are  present,  and  in  supplementing 
them  by  assistance.  In  some  cases,  the  strength  of  the  contrac- 
tions may  be  increased  by  massage  of  the  uterus,  by  hot  vaginal 
douches,  and  by  stimulating  food.  If  the  cervix  does  not  dilate, 
dilatation  must  be  obtained  by  the  use  of  hydrostatic  or  other 
dilators,  or  by  incision,  as  may  be  thought  best.  As  soon  as  the 
necessary  degree  of  dilatation  has  been  obtained,  the  membranes 
must  be  ruptured.  This  may  have  the  effect  of  stimulating  the 
contractions,  and,  if  so,  the  patient  may  be  given  an  opportunity 
of  delivering  herself  naturally.  If,  however,  the  contractions  do 
not  increase  in  strength,  there  is  little  to  be  gained  by  waiting, 
and  delivery  must  be  brought  about  by  artificial  means.  In  some 
cases,  this  may  be  accomplished  by  expression  of  the  foetus  by 
Kristeller's  method."  If  this  fails,  and  the  head  is  still  free  above 
the  brim,  version  and  extraction  may  be  performed,  or,  if  the 
head  is  fixed,  the  forceps  may  be  applied. 

If  contractions  do  not  recur  after  the  expulsion  of  the  foetus,  a 
similar  course  must  be  adopted,  and  the  artificial  removal  of  the 
after-birth  carried  out.  Here,  again,  expression  is  first  tried,  and 
if  this  fails,  the  placenta  must  be  removed  manually.  In  such 
cases,  the  danger  of  post-partum  haemorrhage  is  very  great,  and 
the  operator  must  be  thoroughly  prepared  for  its  occurrence.  It 
is  well  to  commence  by  giving  a  full  dose  of  ergot  by  the  mouth 
or  hypodermically,  and  then  a  hot  uterine  douche  as  soon  as  the 
placenta  has  been  removed.     In  all  cases,  the  necessary  imple- 

*  Berliner  Klin.  Wochenschrifl,  1867,  No.  6;  Monatss.  filr  Geburts. ,  vol.  xxix., 
P-  237- 


SECONDARY  UTERINE  INERTIA  713 

ments  and  materials  for  tamponing  the  cavity  of  the  uterus  must 
be  at  hand. 

Prognosis.  —  The  presence  of  primary  uterine  inertia  very 
materially  increases  the  dangers  of  parturition  both  for  the  mother 
and  the  foetus.  If  the  former  is  allowed  to  remain  too  long 
undelivered,  serious  lesions  may  result  from  the  prolonged  pressure 
of  the  head  on  the  pelvic  soft  parts,  and  sapraemic  intoxication 
may  result  from  decomposition  of  the  liquor  amnii,  while  in 
extreme  cases  death  may  occur  from  exhaustion.  Delivery  itself 
is  often  difficult  in  consequence  of  the  incomplete  dilatation  of  the 
cervix,  and  lacerations  of  the  latter  may  result,  while  the  non-con- 
traction and  retraction  of  the  uterine  muscle,  during  the  third 
stage  of  labour,  may  cause  profuse  and  fatal  post-partum  haemor- 
rhage. So  far  as  the  foetus  is  concerned,  there  is  no  great  increase 
of  danger  so  long  as  the  head  remains  above  the  brim,  as  there 
is  but  slight  pressure  upon  it.  Prolonged  delay  after  the  head 
has  passed  into  the  pelvis  will,  however,  result  in  the  death  of  the 
foetus,  as  there  is  necessarily  some  interference  with  the  circula- 
tion. Further,  artificial  delivery,  no  matter  how  carefully  carried 
out,  is  always  accompanied  by  a  somewhat  higher  rate  of  foetal 
mortality,  than  is  spontaneous  delivery.  This  is  particularly  the 
case  when  version  and  extraction  have  to  be  performed  in  order 
to  effect  the  delivery  of  the  foetus. 

Secondary  Uterine  Inertia. — Secondary  uterine  inertia  is  the 
term  applied  to  inertia  which  occurs  after  the  patient  has  been  in 
labour  for  some  time.  The  contractions  of  the  uterus  may  have 
been  of  full  strength  at  the  commencement  of  labour,  or  even  of 
greater  strength  than  usual,  but  then  gradually  become  weaker 
or  in  some  cases  cease  altogether.  Secondary  uterine  inertia  is 
a  more  common  occurrence  than  is  primary  inertia. 

Aetiology. — Any  of  the  conditions  which  have  been  mentioned 
as  a  cause  of  primary  inertia  may  also,  if  less  marked,  cause 
secondary  inertia,  as  they  may  so  affect  the  uterine  muscle  that 
it  may  be  capable  of  contracting  normally  for  a  certain  time,  but 
then  may  not  be  strong  enough  to  continue  so  contracting,  with 
the  result  that  a  condition  of  inertia  supervenes.  In  addition 
to  these  causes,  any  factor  which  tends  to  offer  an  obstruction  to 
the  birth  of  the  foetus  may  also  produce  exhaustion  of  the  uterine 
muscle,  and  so  be  a  cause  of  secondary  inertia.  Such  obstruction 
may  occur  in  any  of  the  following  conditions  :  — 

(1)  Abnormalities  of  the  foetus  as  regards  presentation,  position, 
or  size. 

(2)  Want  of  correlation  between  the  axis  of  the  uterus  and  that 
of  the  pelvic  brim,  as  a  result  of  which  the  foetal  head  is  driven 
against  the  pelvic  bones,  instead  of  into  the  cavity. 

(3)  Pelvic  contraction. 

(4)  Tumours  or  stenosis  of  the  maternal  soft  parts. 

(5)  Overdistension  of  any  of  the  pelvic  viscera. 


7i4  THE  PATHOLOGY  OF  LABOUR 

Another  cause  of  secondary  inertia,  and  one  which  belongs  to 
a  different  class,  is  to  be  found  in  failure  of  the  auxiliary  forces 
of  labour — that  is  to  say,  failure  of  the  contractions  of  the 
abdominal  and  other  voluntary  muscles.  This  may  be  the  result 
of  deficient  development  of,  or  failure  to  exert,  these  muscles. 

Symptoms. — The  symptoms  of  secondary  inertia  are  identical 
with  those  of  primary  inertia,  save  that  they  appear  some  time 
after  labour  has  started,  and  are  not  present  from  the  commence- 
ment, as  in  the  primary  form.  In  many  cases,  the  contractions  of 
the  uterus  may  have  been  exceptionally  strong  during  the  early 
part  of  labour,  and  then  gradually  become  weaker  or  perhaps  die 
away  altogether.  If  the  patient  obtains  the  needed  rest,  the  con- 
tractions will  in  some  cases  return  in  their  normal  strength  and 
labour  terminate  naturally. 

Diagnosis. — Secondary  uterine  inertia  can  only  be  confused  with 
one  condition — that  known  as  tonic  contraction  of  the  uterus. 
In  this,  the  contractions,  instead  of  being  intermittent,  are 
continuous,  and  there  is  no  period  of  relaxation.  Herman* 
insists  on  the  importance  of  distinguishing  between  these  two 
conditions,  and  on  the  danger  that  exists  of  confusing  them. 
Both  usually  occur  after  labour  has  been  unduly  prolonged,  and 
in  both  the  normal  recurrence  of  uterine  contractions  has  ceased. 
Here,  however,  the  similarity  stops.  In  secondary  inertia,  the 
condition  of  the  patient  is  good,  her  aspect  is  one  of  rest,  she  is 
not  suffering  pain,  and  her  pulse,  temperature,  and  respiration 
are  at  first  unaffected.  In  tetanus  of  the  uterus,  on  the  other 
hand,  her  aspect  is  anxious,  her  pulse  is  rapid,  increasing  in 
frequency,  and  small,  and  the  rate  of  her  respiration  is  increased. 
On  palpation  of  the  abdomen,  in  inertia,  the  uterus  is  found  to  be 
flaccid,  the  fcetal  parts  can  readily  be  felt,  and  there  is  no  marked 
tenderness ;  in  tetanus,  the  uterus  is  hard,  the  foetal  parts  are 
scarcely  perceptible,  and  the  patient  cries  out  with  pain  on  the 
uterus  being  touched.  On  vaginal  examination,  in  inertia,  there 
is  little  or  no  caput  succedaneum  on  the  presenting  part  unless 
the  contractions  have  previously  been  severe,  and  the  part  can  be 
pushed  upwards  if  it  has  not  descended  into  the  pelvic  cavity  ;  in 
tetanus,  there  is  usually  a  large  caput,  and  the  presenting  part, 
even  if  still  free  at  the  brim,  can  only  be  pushed  upwards  if  con- 
siderable force  is  used. 

Treatment. — The  treatment  of  secondary  inertia  differs  materially 
from  that  of  the  primary  form.  The  reason  for  this  has  been 
mentioned.  In  the  primary  form,  there  is  practically  no  hope  of 
normal  contractions  occurring,  and,  consequently,  the  indication 
is  to  help  the  existing  contractions  to  deliver  the  foetus.  In  the 
secondary  form,  on  the  other  hand,  the  uterus  is  frequently  only 
in  a  condition  of  temporary  exhaustion,  and,  if  a  period  of  rest 
is  given  to  the  tired  muscle,  contractions  of  the  necessary  strength 
will  return,  and  delivery  be  effected  by  the  natural  efforts.  Ac- 
*  '  Difficult  Labour,'  p.  127. 


SPASMODIC  AND  IRREGULAR   UTERINE  CONTRACTIONS     715 

cordingly,  the  indication  for  treatment  in  the  latter  form  is  to 
give  the  patient  an  interval  of  as  complete  rest  as  possible,  and 
at  the  same  time  to  remove  any  obstacle  that  may  be  in  the 
way  of  the  birth  of  the  child,  and,  when  the  period  of  rest  is 
over,  to  endeavour  to  stimulate  the  uterine  contractions  as  much 
as  possible. 

Accordingly,  in  secondary  inertia  we  commence  by  determining, 
if  possible,  the  cause.  If  an  obstacle  to  delivery  is  discovered, 
we  try  to  remove  it.  In  this  connection,  the  condition  of  the 
bladder  and  rectum  must  be  particularly  ascertained,  as  disten- 
sion of  these  viscera  is  one  of  the  commonest  causes  of  inertia. 
If  they  are  full,  they  must  be  emptied  in  the  usual  manner.  If 
there  are  any  deviations  of  the  uterus,  which  destroy  the  correla- 
tion between  the  uterine  and  pelvic  axes,  they  must  be  corrected 
by  the  application  of  a  binder  and  of  pads  so  placed  as  to  push 
the  uterus  into  its  proper  position  and  to  keep  it  there.  Other, 
and  more  serious,  obstacles  to  delivery  must  be  suitably  treated, 
and  if  possible  removed. 

If  the  inertia  still  continues,  the  next  step  consists  in  ad- 
ministering an  opiate,  to  make  the  patient  sleep.  As  we  desire 
this  to  act  quickly,  some  preparation  of  opium  or  its  alkaloids 
is  the  most  suitable,  and  either  Tr.  Opii  (1T\  30  to  TT^  40),  or 
morphia  (gr.  \  to  -|),  may  be  given.  This  will,  in  all  probability, 
give  the  patient  a  couple  of  hours'  sleep,  and  when  she  awakes 
the  contractions  will  return,  or,  if  they  do  not  do  so  at  once, 
they  may  often  be  induced  by  administering  a  hot  vaginal  douche, 
and  by  massage  of  the  uterine  walls.  If,  in  spite  of  our  efforts, 
contractions  cannot  be  provoked,  the  foetus  must  be  expressed  or 
extracted  by  forceps,  as  in  primary  inertia. 

Prognosis. — The  prognosis  for  both  mother  and  infant  is  not  at 
all  so  serious  in  secondary  as  in  primary  inertia.  The  contrac- 
tions are  usually  stronger  in  the  former  variety,  and,  even  if  they 
are  not  sufficiently  strong  to  expel  the  foetus,  they  return  after  its 
delivery  in  sufficient  force  to  expel  the  placenta  and  to  prevent 
post-partum  haemorrhage.  Further,  as  secondary  inertia  usually 
occurs  during  the  second  stage  of  labour,  there  is  not  the  same 
difficulty  in  delivering  the  foetus  as  there  is  when  inertia  com- 
mences prior  to  the  dilatation  of  the  uterine  orifice. 


SPASMODIC    AND    IRREGULAR    UTERINE 
CONTRACTIONS 

Spasmodic  contraction  was  the  term  applied  by  Winckel  to  any 
contraction  of  the  uterus  which  was  abnormally  painful,  or  faulty  as 
regards  its  direction,  duration,  or  effect.  Two  separate  conditions 
are  included  under  this  term  : — Spasmodic  contraction  of  the 
body  of  the  uterus  ;  and  spasmodic  contraction  of  the  cervix. 


716  THE  PATHOLOGY  OF  LABOUR 

Spasmodic  Contraction  of  the  Body. — Spasmodic  contraction 
of  the  body  of  the  uterus  may  show  itself  by  the  occurrence  of  con- 
tractions, which  are  more  violent,  more  painful,  and  more  irregular 
in  their  onset  than  is  normal.  It  may  occur  as  an  intermittent 
or  clonic  spasm,  or  as  a  continuous  spasm,  the  so-called  tetanus 
uteri.  Clonic  contractions  may  occur  in  groups,  several  very 
rapidly  following  one  another,  and  then  ceasing  for  a  longer 
interval.  In  tetanus  uteri,  the  normal  intermittent  contractions 
are  replaced  by  a  state  of  continuous  contraction,  and  a  persistent 
condition  of  the  uterine  muscle  is  produced  similar  to  that  found 
at  the  acme  of  a  contraction. 

JEtiology. — Intermittent  or  clonic  spasm  sometimes  occurs  in 
a  uterus  which  is  the  subject  of  inflammatory  conditions,  such 
as  endo-cervicitis  or  old-standing  gonorrhceal  endometritis.  Some- 
times, such  a  spasm  represents  an  extra  effort  on  the  part  of  the 
uterus  to  overcome  some  obstruction  to  the  expulsion  of  the 
foetus.  Occasionally,  it  is  due  to  mechanical  irritation  of  the 
uterus,  by  too  frequent  vaginal  examinations,  by  prolonged  intra- 
uterine manipulations  as  in  the  performance  of  version,  or 
possibly  by  too  forcible  massage  of  the  uterine  wall. 

Tetanic  or  tonic  spasm  of  the  uterus  is  most  frequently  the 
result  of  an  obstruction  to  the  expulsion  of  the  fcetus.  It  may 
also  result  from  the  administration  of  oxytocics,  particularly 
ergot. 

Symptoms. — The  symptoms  of  intermittent  and  of  continuous 
spasm  are  very  similar.  The  principal  symptoms  are  due  to 
the  strength  and  persistence  of  the  contraction.  The  uterus 
during  the  spasm  is  tense,  hard,  and  tender,  so  that  it  is  difficult 
or  impossible  to  palpate  the  foetal  parts.  The  pain  caused  by 
the  contraction  is  very  great,  and  causes  the  patient  to  cry  out 
and  to  resist  any  efforts  which  may  be  made  to  examine  her 
either  abdominally  or  vaginally.  The  rate  of  respiration  and  of 
the  pulse  increases,  and  if  labour  is  delayed  the  temperature  rises. 
Frequent  vomiting  is  also  a  common  accompaniment.  If  the 
condition  is  allowed  to  persist,  the  pressure  on  the  pelvic  nerves 
and  bloodvessels  leads  to  the  occurrence  of  cramps  in  the  legs, 
and  swelling,  particularly  in  the  region  of  the  vulva.  On  making 
a  vaginal  examination,  the  presenting  part  is  usually  found  to  be 
firmly  wedged  in  the  pelvis,  and  a  large  caput  succedaneum  has 
formed.  The  persistence  of  tonic  spasm  tends  to  bring  about 
the  death  of  the  foetus,  as  it  interferes  with  the  placental  circula- 
tion. 

Diagnosis. — The  diagnosis  of  clonic  spasm  of  the  uterus  can 
readily  be  made.  The  contractions  are  more  violent,  cause  more 
pain,  occur  at  irregular  intervals,  and  are  associated  with  more 
constitutional  disturbance  than  is  normal. 

Tonic  contraction  of  the  uterus  has  to  be  distinguished  from 
secondary  uterine  inertia.  The  points  of  distinction  have  been 
already  pointed  out,  and  if  we  remember  that  it   is   possible  to 


SPASMODIC  CONTRACTION  OF  THE  CERVIX  717 

confuse  the  two  conditions,  it  is  not  difficult  to  distinguish  between 
them. 

Treatment. — The  prophylactic  treatment  of  spasmodic  contrac- 
tion consists  in  removing  any  obstruction  to  the  birth  of  the 
fcetus,  and  in  avoiding  unnecessary  vaginal  examinations  and  the 
use  of  oxytocics.  If  clonic  spasms  occur,  they  may  be  relieved 
in  the  first  stage  by  the  internal  administration  of  chloral  in 
20-grain  doses,  or  morphia  hypodermically — \  to  h  grain  dose. 
The  chloral  may  be  repeated  every  three  or  four  hours,  but  not 
more  than  three  doses  should  be  administered.  Considerable 
relief  may  also  be  given  by  placing  the  patient  in  a  hot  bath,  and 
allowing  her  to  remain  there  for  from  ten  to  twenty  minutes. 
Care  must,  however,  be  taken  to  be  sure  that  there  is  no  risk 
of  the  infant  being  expelled  during  this  time,  and  that  assistance 
is  at  hand  in  case  it  is  required.  Hot  vaginal  douches  delivered 
at  a  low  pressure  will  also  sometimes  give  relief.  If  these 
measures  are  unavailing,  chloroform  must  be  administered  during 
the  spasms. 

The  treatment  of  tonic  contraction  is  similar,  save  that  delivery 
should  be  at  once  effected  under  chloroform  if  the  condition  of  the 
cervix  permits  the  application  of  forceps.  If  the  cervix  is  not 
sufficiently  dilated  to  enable  this  course  to  be  adopted,  the  various 
measures  enumerated  above  may  be  tried,  unless  the  other 
symptoms  of  the  patient  point  to  the  necessity  for  immediate 
delivery.  In  such  a  case,  the  cervix  must  be  incised  or  dilated, 
and  the  forceps  then  applied.  Such  cases  are,  however,  very 
rare,  unless  a  spasmodic  condition  of  the  circular  fibres  of  the 
uterine  orifice  is  associated  with  spasm  of  the  body.  This  class 
of  case  will  be  referred  to  in  a  following  paragraph. 

Prognosis. — All  forms  of  spasmodic  contraction  of  the  uterus 
are  detrimental  to  the  foetus,  in  proportion  to  the  duration  of  the 
spasm,  as  they  interfere  with  the  free  circulation  of  maternal 
blood  in  the  placental  sinuses.  In  tonic  contraction,  the  foetal 
prognosis  is  especially  bad,  and  the  death  of  the  fcetus  will 
usually  result  unless  its  early  delivery  is  effected.  The  maternal 
prognosis  depends  upon  the  duration  of  labour.  If  the  patient 
is  allowed  to  remain  undelivered  for  too  long  a  period  after  tonic 
contraction  has  set  in,  there  is  danger  of  rupture  of  the  thinned 
lower  uterine  segment,  as  retraction  proceeds  steadily  all  the 
time.  The  persistence  of  the  spasm  during  the  third  stage  is  also 
a  serious  matter,  as  it  leads  to  the  retention  of  the  placenta  and 
renders  its  artificial  removal  difficult. 

Spasmodic  Contraction  of  the  Cervix. — Spasmodic  contrac- 
tion of  the  circular  fibres  of  the  cervix  may  occur  during  any  stage 
of  labour,  with  the  result  that  the  expulsion  of  the  fcetus  or  of  the 
placenta,  as  the  case  may  be,  is  prevented.  The  terms  '  trismus 
uteri '  and  '  stricture  of  the  uterus  '  are  also  applied  to  this  con- 
dition.    A  similar  contraction  of  the  circular  fibres  of  the  body 


718  THE  PATHOLOGY  OF  LABOUR 

of  the  uterus  may  also  occur,  with  the  result  that  the  uterine 
cavity  is  divided  into  two  parts  by  an  hour-glass  constriction  at 
the  level  of  the  contracted  fibres. 

/Etiology. — The  two  principal  causes  of  spasmodic  contraction 
of  the  cervix  aire  previous  inflammatory  conditions  of  that  part, 
and  mechanical  irritation  during  labour.  Premature  rupture  of 
the  membranes  may  also  help  to  cause  spasm,  as  the  direct 
pressure  of  the  presenting  part  may  irritate  the  undilated  cervical 
tissues.  Cervical  spasm  is  also  said  to  be  not  uncommonly 
associated  with  placenta  praevia,  but  our  own  experience  does  not 
support  such  a  statement. 

Symptoms. — The  most  prominent  symptom  consists  in  delay  in 
the  dilatation  of  the  cervix.  On  examination  per  vaginam,  the 
edges  of  the  cervix  are  found  to  be  thin  and  tense,  and  any 
attempt  at  dilatation  gives  rise  to  extreme  pain.  The  remaining 
symptoms  are  -dependent  upon  the  obstruction  to  the  descent  of 
the  presenting  part,  and  are  those  of  delayed  labour.  If  spasmodic 
contraction  of  the  cervix  occurs  during  the  third  stage,  it  causes 
retention  of  the  placenta.  In  such  cases,  the  contraction  usually 
occurs,  not  at  the  level  of  the  cervix,  but  in  the  neighbourhood  of 
the  retraction  ring.  It  may  be  associated  with  profuse  haemor- 
rhage, as  the  retention  of  the  placenta  after  its  detachment 
prevents  the  proper  retraction  of  the  uterine  muscle. 

Diagnosis. — The  diagnosis  of  spasmodic  contraction  of  the  cervix 
is  made  by  noting  the  tense  and  sensitive  condition  of  the  cervical 
tissues.  They  feel  to  the  examining  finger  like  an  overstretched 
rubber  ring,  with  sharp  or  string-like  edges. 

Treatment. — Spasmodic  contraction  of  the  cervix  is  a  most  un- 
pleasant condition  with  which  to  meet,  but,  fortunately,  it  is  of 
comparatively  rare  occurrence.  In  the  past,  under  the  name  of 
'  rigid  os,'  it  used  to  be  the  bugbear  of  the  obstetrician,  and 
particularly  of  the  too  conscientious  obstetrician,  as  the  more 
vaginal  examinations  he  made,  the  greater  the  proportion  of 
cases  of  '  rigid  os  '  that  occurred  in  his  practice.  Now,  when 
it  is  understood  that  many  vaginal  examinations  are  not  only 
unnecessary  but  dangerous,  '  rigid  os,'  or  spasmodic  contraction 
of  the  cervix,  is  a  condition  of  extreme  rarity,  and  if  it  occurs 
is  usually  due  to  some  structural  alteration  in  the  cervix.  In 
such  cases,  relaxation  may  be  obtained  by  the  administration  of 
hot  vaginal  douches,  and  of  sedatives,  such  as  chloral,  given 
either  by  the  mouth  or  in  a  rectal  injection.  If  there  is  no 
immediate  indication  for  terminating  labour,  we  should  wait 
as  long  as  possible,  since  in  many  cases  the  spasm  will  pass 
off.  If  it  does  not  do  so,  and  the  condition  of  the  patient 
or  the  foetus  necessitates  the  extraction  of  the  latter,  the 
cervix  must  he  dilated  or  incised.  Dilatation  by  hydrostatic 
dilators,  or  Frommer's  dilator,  is  the  more  suitable  method  to 
adopt  in  a  multipara,  as  will  be  understood  if  the  mechanism  of 
cervical  dilatation  in  such  a  case  is  remembered.     In  the  case 


SPASMODIC  CONTRACTION  OF  THE  CERVIX  719 

of  a  primipara,  in  whom  the  edges  of  the  uterine  orifice  are 
thin,  multiple  incisions  are  easily  carried  out,  and  are  more 
satisfactory.  When  spasmodic  contraction  occurs  during  the 
third  stage,  it  may  pass  off  if  all  friction  of  the  uterus  is  stopped. 
If  it  does  not  do  so,  the  administration  of  a  little  chloroform 
may  be  effectual.  If  it  becomes  necessary  to  remove  the  placenta, 
dilatation  of  the  stricture  may  be  effected  by  passing  the  fingers, 
in  the  shape  of  a  wedge,  gently  and  gradually  through  the 
orifice.  Much  force  must  not  be  employed,  as  sometimes  it  is 
easier  to  tear  the  uterus  than  to  dilate  the  stricture. 

Prognosis. — -The  prognosis  both  for  mother  and  foetus  in  cases 
of  spasmodic  contraction  of  the  cervix  depends  upon  the  time 
during  which  the  spasm  persists.  If  it  does  not  relax,  rupture  of 
the  uterus  may  result,  owing  to  the  obstruction  offered  to  the 
descent  of  the  foetus,  and  death  of  the  foetus  from  the  long-con- 
tinued pressure  to  which  it  is  subjected.  Spasmodic  contraction 
during  the  third  stage  may  result  in  serious  post-partum  haemor- 
rhage. 


CHAPTER  II 
CONTRACTED  PELVIS 

Contracted    Pelvis  —  Classification  —  Frequency  —  Diagnosis  —  Pelvimetry  — 
Symptoms,  during  pregnancy,  during  labour — Treatment — Prognosis. 

The  pelvis  is  said  to  be  contracted  when  any  of  its  diameters 
are  shorter  than  normal.  All  the  diameters  of  the  pelvis  may  be 
so  affected,  or  only  certain  diameters  at  certain  levels.  Thus,  any 
one  diameter,  or  all  the  diameters  of  the  brim,  of  the  cavity,  and  of 
the  outlet  may  be  diminished  in  length,  or  the  diminution  may 
involve  one  or  more  of  these  different  levels,  without  affecting  the 
others. 

Classification. — Although  the  importance  of  contraction  of  the 
pelvis  as  a  cause  of  obstruction  during  labour  has  been  recognised 
for  some  hundreds  of  years,  it  is  only  within  a  comparatively 
recent  period  that  the  frequency  of  its  occurrence  has  been 
realised,  and  that  attempts  have  been  made  to  classify  the  various 
types  of  deformity  in  accordance  with  the  changes  that  are 
actually  present  in  the  pelvis.  Many  authors  have  employed  a 
classification  depending  upon  the  aetiology  and  pathology  of  the 
various  deformities  met  with,  and  scientifically  such  is  without 
doubt  the  more  correct,  but,  from  the  point  of  view  of  treatment, 
it  is  far  more  important  to  group  together  those  pelves  in  which 
a  similar  change  of  form  is  present,  irrespective  of  the  cause  or 
pathology  of  the  individual  varieties.  The  following  classification 
will  therefore  be  adopted  : — 

I.  Generally  contracted  pelvis, 
(i)  Generally  contracted  pelvis. 

(a)  Non-rachitic. 

(b)  Rachitic. 
(2)  Dwarf  pelvis. 

II.  Flattened  pelvis. 
(1)  Flat  pelvis. 

(a)  Non-rachitic. 

(b)  Rachitic. 

720 


THE  CLASSIFICATION  OF  CONTRACTED  PELVIS  721 

(2)  Generally  contracted  flat  pelvis. 

(a)  Non-rachitic. 

(b)  Rachitic. 

(3)  Pelvis  of  congenital  dislocation  of  the  hips. 

III.  Obliquely  distorted  pelvis. 

(1)  By  spinal  curvature — kypho-scoliotic  pelvis. 

(2)  By  imperfect  or  abolished  use  of  one  lower  limb — 

coxalgic  pelvis. 

(3)  By  asymmetry  of  the  sacrum — unilateral  synos- 

totic  pelvis. 

IV.  Transversely  contracted  pelvis. 

(1)  The  bilateral  synostotic  pelvis,  or  Robert's  pelvis. 

(2)  The  kyphotic  pelvis. 

V.  Funnel-shaped  pelvis. 

VI.  Compressed  or  tri-radiate  pelvis. 

(1)  The  rachitic  tri-radiate  pelvis. 

(2)  The  osteomalacic  tri-radiate  pelvis. 

VII.  Spondylolisthetic  pelvis. 
VIII.  Pelvis  narrowed  by  fractures,  exostoses,  or  other 

FORM    OF    TUMOUR. 

'  IX.  Split  pelvis. 

For  convenience  of  description,  obstetricians  are  accustomed 
to  divide  symmetrical  contractions  into  four  degrees,  according 
to  the  length  of  the  true  conjugate.  The  limits  of  each  degree 
differ  in  the  case  of  flattened  and  of  generally  contracted  pelvis, 
as  the  disproportion  between  the  head  and  the  pelvis  is  naturally 
greater  when  transverse  narrowing  is  associated  with  antero- 
posterior narrowing.  Accordingly,  as  the  following  table  shows, 
the  limits  of  the  degrees  in  generally  contracted  pelvis  are  a 
centimetre,  or,  roughly,  a  quarter  of  an  inch,  more  than  in 
flattened  pelvis  : — 


Degrees. 

Length  of  Conjugate  in  Flat 
Pelvis. 

Length  of  Conjugate  in 
Generally  Contracted  Pelvis. 

1st 

4  to  3 J  ins.  (10  to  8-25  cms. 

4  to  3%  ins.  (10  to  9  cms. 

2nd 

approx.) 
3^  to  2f  ins.  (8-25  to  7  cms 

approx.) 
3^  to  3  ins.  (9  to  7-5  cms. 

3rd 

approx.) 
2f  to  2|  ins.  (7  to  5-5  cms. 

approx. ) 
3  to  2|  ins.  (75  to  65  cms. 

4th 

approx.) 
below  i\  ins.  (5 "75   cms. 

approx. ) 
below    2.h    ins.    (6  "5    cms. 

approx.) 

approx.) 

46 


722  THE  PATHOLOGY  OF  LABOUR 

Frequency.— The  frequency  of  contracted  pelvis,  in  either  private 
or  hospital  practice  in  these  countries,  is  very  difficult  to  deter- 
mine. In  the  first  place,  the  proportion  of  cases  varies  greatly 
in  different  localities.  In  the  second  place,  even  in  maternity 
hospitals,  many  cases  of  minor  degrees  of  contraction  are  not 
diagnosed,  and,  as  statistics  are  not  as  carefully  kept  as  they 
might  be,  it  is  difficult  to  obtain  any  very  accurate  information 
from  them.  The  statistics  compiled  by  Winckel*  are  very  com- 
plete, but  they  refer  to  a  country  in  which  the  proportion  of 
cases  of  contracted  pelvis  is  much  higher  than  it  is  in  these 
countries.  This  authority  makes  the  statement  that  '  contraction 
of  the  pelvis  is  present  in  from  10  to  15  per  cent,  of  all 
parturient  women,  but  that  usually  only  5  per  cent,  are  recog- 
nised even  in  clinical  institutions  on  account  of  their  effect  on 
labour.'  His  actual  figures  show  that  at  Dresden,  out  of  10,679 
cases,  356  had  contracted  pelvis,  or  2 -8  per  cent.,  and  that  of 
these  cases,  41  per  cent,  required  artificial  assistance.  It  may  be 
useful  to  compare  with  these  the  figures  of  the  Rotunda  Hospital, 
as  they  probably  furnish  one  of  the  most  reliable  means  of  deter- 
mining the  relative  frequency  of  contraction  in  these  countries. 
The  statistics  from  1889  to  1903  show  that  out  of  20,000  cases, 
113  had  contracted  pelvis,  or  0-56  per  cent.  As  there  is  a  little 
uncertainty  attending  the  exact  figures  for  three  of  these  years, 
it  is  probable  that  about  one  per  cent,  is  the  true  proportion. 

The  relative  frequency  with  which  the  different  varieties  of 
contracted  pelvis  are  met,  according  to  Winckel's  figures,  is  as 
follows : — 

Flattened  pelvis  occurred  in  -  -  95*25  per  cent,  of  cases  of  deformity. 

Obliquely  contracted  pelvis  in  -     2*38 

Generally  contracted  pelvis  in  -     1*42 

Spondylolisthetic  pelvis  in     -  -     0*47 

Transversely  contracted  at  outlet  in     0*24 

Osteomalacic   -----     0^24 

The  various  forms  of  contracted  pelvis  may  be  divided  into  two 
groups,  according  to  the  relative  frequency  with  which  they 
are  met :  — 

(1)  The  common  forms  of  contracted  pelvis. — The  forms  of 
contracted  pelvis,  which  can  be  regarded  as  of  relatively  common 
occurrence  in  these  countries,  are  all  included  in  the  two  classes — 
generally  contracted  pelvis,  and  flattened  pelvis.  The  commonest 
form  of  all  is  the  rachitic  flat  pelvis. 

(2)  The  rarer  forms  of  contracted  pelvis. — In  this  group  are 
included  all  the  other  classes  which  have  been  enumerated,  and 
also  the  generally  contracted  rachitic  pelvis,  the  dwarf  pelvis,  the 
generally  contracted  and  flat  non-rachitic  pelvis,  and  the  pelvis  of 
congenital  dislocation  of  the  hips,  all  of  which  are  included  in  the 
classes  of  generally  contracted  and  of  flattened  pelvis. 

*  Op.  cit.,  p.  461. 


THE  DIAGNOSIS  OF  CONTRACTED  PELVIS  723 

The  Diagnosis  of  Contracted  Pelvis. 

A  provisional  diagnosis  of  contracted  pelvis  is  made  from  the 
appearance,  history,  and  symptoms  of  the  patients,  and  is  con- 
firmed by  means  of  pelvimetry,  by  which  also  the  exact  form 
and  degree  of  contraction  present  is  ascertained. 

History. — The  chief  points  on  which  information  should  be 
obtained  are  the  childhood  of  the  patient  and  her  previous  labours. 
As  regards  her  childhood,  the  occurrence  of  rickets  must  be  care- 
fully looked  for.  Evidence  of  such  an  occurrence  is  to  be  found 
in  a  history  of  late  dentition,  inability  to  walk  at  the  usual  age,  or 
temporary  loss  of  the  power  of  walking.  According  to  one 
writer,*  the  history  is  of  no  value  in  the  diagnosis  of  past  rickets, 
first  because  the  patient  usually  knows  nothing  of  her  childhood, 
and  secondly  because,  even  if  obtained,  the  history  affords  no 
information  of  value  in  the  treatment  of  the  case.  This  is  scarcely 
quite  correct.  A  negative  history  is  naturally  of  no  value,  and 
even  a  positive  history  of  ability  to  walk  at  the  proper  time  may 
be  valueless.  On  the  other  hand,  a  positive  history  of  inability  to 
walk  is  of  considerable  value,  not  in  showing  the  proper  treatment 
to  adopt,  but  in  indicating  the  necessity  for  examining  the  patient 
carefully,  and  perhaps  of  performing  pelvimetry  with  a  view  to 
ascertaining  the  exact  condition  of  the  pelvis. 

The  history  of  previous  labours  affords  more  definite  informa- 
tion. If  the  patient  has  been  normally  confined  at  term  of  a 
normally  sized  infant,  it  is  positive  proof  that  she  has  not  a  con- 
tracted pelvis.  If,  on  the  other  hand,  there  is  a  history  of  previous 
difficult  labours  —  prolonged  labour,  difficult  forceps  cases,  or 
craniotomy — the  probability  of  a  contracted  pelvis  is  very  great. 
A  history  which  is  very  suggestive  of  a  slight  degree  of  pelvic 
contraction  is  as  follows : — The  first  labour  is  very  tedious,  delivery 
being  finally  effected  by  the  forceps,  the  foetus  perhaps  being  dead. 
The  second  labour  is  also  tedious,  but  perhaps  ends  naturally. 
The  third  labour  is  still  more  tedious  and  ends  in  the  performance 
of  craniotomy  ;  the  fourth  also  ends  in  craniotomy.  A  history  of 
the  birth  of  several  dead  children,  which  were  alive  at  the  com- 
mencement of  labour,  is  also  very  suggestive  of  pelvic  deformity. 

The  presence  of  one  of  the  rarer  forms  of  pelvic  deformity  is 
suggested  by  a  history  of  osteomalacia,  hip  or  spinal  disease,  or 
fracture  of  the  pelvis. 

Appearance. — Any  of  the  following  conditions  suggest  pelvic 
deformity  : — 

(1)  Very  small  stature. 

(2)  Pendulous  abdomen. 

(3)  Curvature  of  the  spine — kyphosis,  lordosis,  or  scoliosis, 
especially  when  affecting  the  lumbar  region. 

(4)  Crooked  legs,  legs  of  unequal  length,  or  absence  of  one  leg  ; 
and  prominence  of  or  impaired  mobility  in  one  hip. 

*  Herman. 

46 — 2 


724  THE  PATHOLOGY  OF  LABOUR 

Abdominal  and  Vaginal  Examination. — Abdominal  palpation 
and  vaginal  examination  afford  most  important  information,  both 
during  pregnancy  and  labour.  Abdominal  palpation  informs  us 
of  the  relation  of  the  presenting  part  to  the  brim  of  the  pelvis.  If 
the  head  presents  and  is  fixed,  we  know  for  certain  that  we  are 
not  dealing  with  a  case  of  contraction  of  the  brim,  and  as  this  is 
the  commonest  site  of  contraction,  it  is  probable  that  there  is 
no  contraction  present.  On  the  other  hand,  if  the  head  is  felt 
high  above  the  brim  and  is  movable  at  a  time  at  which  it  ought 
to  be  fixed — i.e.,  during  the  last  few  weeks  of  pregnancy  in 
primiparae  and  shortly  after  the  commencement  of  labour  in 
multiparas,  it  is  extremely  probable  that  there  is  some  degree  of 
pelvic  contraction.  Several  other  conditions,  however,  also  cause 
non-fixation,  so  that  this  condition  must  not  be  regarded  as  a 
certain  proof  of  contraction. 

Vaginal  examination  may  at  once  reveal  the  presence  of  pelvic 
contraction,  as  in  cases  of  marked  contraction  of  the  outlet,  or 
when  we  find  a  low  promontory  within  easy  reach  of  the  finger, 
or  an  exostosis  springing  from  the  pelvic  bones.  A  more  careful 
examination  of  the  sides  of  the  pelvis  may  reveal  flattening  of  one 
or  both  sides  in  an  obliquely  distorted  pelvis,  in  Robert's  pelvis, 
or  in  general  contraction  of  the  brim.  During  labour,  informa- 
tion is  obtained  by  abdominal  palpation  from  the  non-fixation 
and  high  situation  of  the  presenting  part,  and  by  vaginal  examina- 
tion from  the  undue  protrusion  of  the  membranes  into  the  vagina 
during  a  contraction  of  the  uterus. 

Pelvimetry. — The  foregoing  modes  of  making  a  diagnosis  only 
enable  us  to  suspect  the  existence  of  a  contracted  pelvis,  or  at 
most  to  determine  in  a  general  way  that  there  is  actually  some 
contraction,  but  they  will  not  tell  us  either  the  degree  or  the  form 
of  contraction  present.  Accordingly,  in  all  cases  in  which  pelvic 
narrowing  is  suspected,  we  must  resort  to  pelvimetry  to  obtain 
definite  information  on  these  important  points.  The  various 
methods  of  measuring  the  pelvis  have  been  already  described  in 
full,  and  here  we  shall  only  deal  with  the  deductions  that  can  be 
drawn  from  the  results  of  our  measurement. 

The  following  distances  are  measured  by  external  pelvimetry  : — 

(i)  The  distance  between  the  anterior  superior  iliac  spines. 

(2)  The  distance  between  the  most  distant  portions  of  the  iliac 
crests. 

(3)  The  external  conjugate,  and  the  transverse  and  the  antero- 
posterior diameters  of  the  outlet. 

(4)  The  distance  between  the  posterior  superior  iliac  spines. 

(5)  The  distance  between  the  trochanters. 

From  these  measurements,  we  can  get  some  information  as  to 
the  existence  and  nature  of  the  contraction  present,  but  little  or 
none  as  to  the  degree,  save  in  the  case  of  the  measurements  of  the 
diameters  of  the  outlet.  The  information  that  is  obtained  may  be 
stated  as  follows  : — 


THE  DIAGNOSIS  OF  CONTRACTED  PELVIS  725 

(1)  The  external  conjugate  normally  measures  about  8  inches. 
If  in  any  case  it  is  found  to  be  less  than  6\  inches,  there  is 
certainly  some  degree  of  antero-posterior  narrowing  present. 

(2)  The  normal  distance  between  the  anterior  superior  spines  of 
the  ilia  is  io\  inches,  and  between  the  crests  n\  inches.  If  there 
is  considerable  shortening  of  these  distances,  there  is  probably 
some  contraction  present.  According  to  Herman,*  however,  the 
inter-spinous  distance  may  vary  between  9  and  13  inches,  and  the 
inter-cristal  between  10  and  14  inches,  without  much  alteration  in 
the  dimensions  of  the  true  pelvis. 

(3)  The  normal  ratio  of  the  distance  between  the  spines  and 
the  distance  between  the  crests  is  as  io|  to  n|-.  If  the  former 
distance  is  either  equal  to,  or  greater  than,  the  latter,  we  are 
dealing  with  a  case  of  rachitic  pelvis,  as  in  this  form  of  contrac- 
tion the  anterior  extremities  of  the  iliac  crests  are  flared  out- 
wards. 

(4)  The  normal  ratio  of  the  distance  between  the  posterior 
superior  spines  of  the  ilia  and  the  distance  between  the  anterior 
superior  spines  is  as  1  is  to  3,  or  as  1  to  3^.  If  the  former  distance 
is  increased  in  proportion  to  the  latter,  so  that  the  ratio  become 
less  than  1  to  3,  it  points  to  the  presence  of  a  generally  contracted 
pelvis,  as  in  this  form  of  contraction  the  promontory  is  high, 
and  the  posterior  spines  are  not  pulled  inwards  as  much  as  is 
usually  the  case.  If,  on  the  other  hand,  the  distance  between  the 
posterior  superior  spines  is  diminished,  so  that  the  ratio  becomes 
greater  than  1  to  3,  it  points  to  the  presence  of  a  flat  pelvis,  in 
which  the  promontory  is  low,  and  sunk  downwards  and  inwards 
between  the  iliac  bones. 

(5)  The  measurements  of  the  transverse  and  of  the  antero- 
posterior diameters  of  the  outlet  give  the  actual  size  of  the  outlet. 

By  internal  pelvimetry,  we  ascertain  the  actual  length  of  the 
true  conjugate  and  of  the  transverse  diameter  of  the  brim,  and, 
consequently,  the  actual  size  of  the  latter.  From  these  measure- 
ments, and  from  the  measurement  of  the  antero-posterior  and  the 
transverse  diameters  of  the  outlet,  we  learn  the  nature  and  the 
degree  of  the  contraction  present.  The  information  obtained 
may  be  stated  as  follows : — 

(1)  If  both  the  conjugate  and  the  transverse  diameters  of  the 
brim  are  diminished,  but  still  preserve  their  normal  ratio  to  each 
other,  we  are  dealing  with  a  case  of  generally  contracted  pelvis. 
In  such  cases,  it  is  probable  that  there  is  also^some  narrowing  of 
the  outlet. 

(2)  If  the  conjugate  diameter  alone  is  diminished,  we  are 
dealing  with  a  case  of  flat  pelvis. 

(3)  If  both  conjugate  and  transverse  diameters  are  diminished, 
but  the  conjugate  is  diminished  out  of  proportion  to  the  trans- 
verse, we  are  dealing  with  a  case  of  generally  contracted  and  flat 
pelvis. 

*  Op.  cit.,  p.  168. 


726  THE  PATHOLOGY  OF  LABOUR 

(4)  If  the  transverse  diameter  is  much  diminished  and  the  con- 
jugate increased,  we  are  dealing  with  a  case  of  Robert's  pelvis. 

(5)  If  the  transverse  diameter  of  the  outlet  is  much  diminished 
and  there  is  a  marked  increase  in  the  conjugate  of  the  brim,  we 
are  dealing  with  a  kyphotic  pelvis. 

(6)  If  both  antero-posterior  and  transverse  diameters  of  the 
outlet  are  much  diminished,  without  any  noteworthy  increase  in 
the  diameters  of  the  brim,  we  are  dealing  with  a  funnel-shaped 
pelvis. 

Those  varieties  of  contraction,  which  are  associated  with 
marked  deformity  of  the  pelvis,  are  distinguished  by  the  obvious 
changes  which  occur  in  the  shape  of  the  pelvis,  as  in  the  case 
of  the  compressed,  spondylolisthetic,  and  transversely  contracted 
pelves. 

The  Symptoms  of  Contracted  Pelvis. 

The  effects  of  a  contracted  pelvis  are  manifest  not  alone  during 
parturition,  but  also  during  pregnancy,  and  so  it  is  better  to 
discuss  the  symptoms  under  two  heads — during  pregnancy,  and 
during  labour. 

The  Symptoms  of  Contracted  Pelvis  during  Pregnancy. — The 
principal  effect  of  contraction  of  the  pelvis  during  pregnancy  is 
on  the  position  of  the  uterus.  During  the  early  months  of 
pregnancy,  backward  displacement  of  the  uterus  may  occur,  and 
has  been  already  described.  In  most  cases,  this  displacement 
corrects  itself  of  its  own  accord,  as  pregnancy  advances,  but  if — 
as  in  certain  cases  of  contracted  pelvis — the  promontory  projects 
somewhat  over  the  brim,  the  uterus  may  become  caught  below  it 
and  be  unable  to  ascend,  and  thus  an  incarcerated  pregnant 
retroverted  uterus  may  result.  If  incarceration  does  not  occur, 
or  if  it  has  been  corrected,  then,  in  the  later  months  of  pregnancy 
the  narrow  brim  tends  to  push  the  enlarged  uterus  upwards,  and 
so  to  make  it  occupy  a  higher  position  in  the  abdomen  than  is 
usually  the  case.  In  consequence  of  this,  and  also  of  the  lack 
of  the  usual  support  that  the  pelvic  brim  affords,  the  uterus  tends 
to  fall  forwards  against  the  abdominal  wall,  and  to  gradually 
cause  by  its  weight  an  overdistension  of  the  integuments  and 
fascia.  As  this  relaxation  occurs,  the  uterus  falls  more  and  more 
forward,  and  finally  in  extreme  cases  comes  into  a  position  of 
complete  anteversion,  in  which  the  fundus  lies  at  the  same  or 
at  even  a  lower  level  than  the  cervix.  This  condition  is  known 
as  a  pendulous  abdomen. 

Another  effect  of  contracted  pelvis  is  to  cause  mal-presentations, 
due  partly  to  the  loss  of  the  usual  support  that  the  presenting 
vertex  receives  from  the  pelvic  brim,  and  partly  to  the  anteverted 
position  of  the  uterus.  For  similar  reasons,  frequent  changes 
occur  in  the  presenting  part  during  pregnancy. 

The  following  table  shows  the  relative  frequency  of  the  different 


THE  SYMPTOMS  OF  CONTRACTED  PELVIS  DURING  LABOUR     727 


presentations  as  found  by  Spiegelberg*  in  680  cases  of  contracted 
pelvis,  and  side  by  side  with  his  figures  are  placed  for  the  sake  of 
comparison  the  usual  percentage  of  the  presentations  : — 


Presentation. 

Percentage  in  Con- 
tracted Pelvis. 

Percentage  in  all 
Cases. 

Vertex  ... 
Pelvic   ... 

Face     

Brow     ... 

Shoulder 

84-3 
4-8 
2-6 
0-9 

7-4 

95*53 
3-" 
o-6 

0-2 
0-56 

The  Symptoms  of  Contracted  Pelvis  during  Labour. — The  effects 
of  contracted  pelvis  are  naturally  more  manifest  and  more  im- 
portant during  labour  than  during  pregnancy.  It  will  be  con- 
venient to  discuss  them  under  the  following  heads  : — 

(1)  Effect  on  the  relation  of  the  head  to  the  brim. 

(2)  Effect  on  the  foetus. 

(3)  Effect  on  the  mechanism  of  expulsion. 

(4)  Effect  on  the  uterus  and  vagina. 

(5)  Post-partum  effects. 

(1)  The  Effect  on  the  Relation  of  the  Head  to  the  Brim. — The 
altered  relation  between  the  size  of  the  brim  and  the  size  of  the 
foetal  head  in  contracted  pelvis  has  been  already  mentioned,  as 
have  been  the  results  that  occur  during  pregnancy  from  this 
altered  relation.  In  addition  to  these  results,  other  consequences 
follow  during  labour.  First,  and  most  important,  even  in  slight 
degrees  of  contraction,  the  head  does  not  fix  as  early  in  labour 
as  is  usual,  while,  in  the  greater  degrees,  fixation  may  never  occur. 
In  the  latter  case,  the  uterine  contractions  increase  in  strength 
and  endeavour  to  force  the  head  through  the  brim,  and,  failing 
in  this,  either  die  away  completely — a  condition  of  missed  labour 
ensuing,  or  continue  until  rupture  of  the  thinned  lower  uterine 
segment  results.  Secondly,  the  presenting  head  is  prevented  from 
descending  and  filling  the  lower  uterine  segment,  and  the  various 
consequences  of  its  non-descent  follow.  These  have  been  already 
referred  to  in  another  place,  and  need  only  be  enumerated  here. 
The  membranes  protrude  unduly  into  the  vagina  as  a  conical  or 
sausage-shaped  swelling,  early  rupture  occurs,  the  liquor  amnii 
escapes  suddenly  and  completely,  and  the  cord  may  be  swept  down. 
A  remoter  consequence  due  to  the  loss  of  the  dilating  action  of 
the  unruptured  bag  of  membranes  consists  in  the  slow  dilatation 
of  the  uterine  orifice.  In  some  cases,  the  latter  may  dilate  in  the 
usual  manner  at  the  commencement  of  labour,  as  long  as  the 
membranes  remain  intact,  but  on  their  rupture  dilatation  ceases, 
or  perhaps  the  cervix  actually  closes,  to  be  again  dilated  by  the 

*  Op.  cit.,  vol.  ii.,  p.  59. 


728  THE  PATHOLOGY  OF  LABOUR 

presenting  part  as  it  descends.     This  is  a  tedious  process,  and 
materially  increases  the  length  of  labour. 

(2)  The  Effect  on  the  Foetus. — Some  of  the  effects  of  contracted 
pelvis  on  the  foetus  have  been  already  mentioned.  Mal-presenta- 
tions  are  common,  and  prolapse  of  the  cord  tends  to  occur.  In 
consequence  of  the  early  rupture  of  the  membranes  and  the 
complete  escape  of  the  liquor  amnii,  the  full  force  of  the  uterine 
contractions  is  directly  exerted  upon  the  foetus,  and,  in  conse- 
quence, the  latter  is  subjected  to  a  pressure  which,  if  continued  for 
sufficient  time,  causes  its  death.  Next  to  the  death  of  the  foetus 
from  long-continued  compression,  the  most  important  effects  of 
pelvic  contraction  are  to  be  found  in  the  changes  which  take  place 
in  the  foetal  head,  in  consequence  of  the  manner  in  which  it  is 
compressed  by  the  contracted  brim. 

The  compression  of  the  head  by  the  narrow  brim  leads  to  con- 
siderable deformity.  In  consequence  of  the  length  of  labour  and 
the  strength  of  the  uterine  contractions,  the  caput  succedaneum 
is  considerably  larger  than  in  normal  cases.  It  is  limited  at 
first  to  the  part  of  the  head  which  is  below  the  dilating  rim  of 
the  external  os,  but  later  as  labour  advances  it  covers  all  that 
part  of  the  head  that  lies  below  the  girdle  of  pelvic  contact. 
Occasionally,  two  distinct  swellings  may  be  found  after  delivery, 
one  corresponding  to  the  pressure  of  the  cervical  tissues,  the 
other  to  the  pressure  of  the  pelvic  bones  (Herman).  Another 
consequence  of  compression  is  the  excessive  moulding  of  the 
cranial  bones  that  occurs  in  cases  in  which  the  disproportion 
between  the  head  and  pelvis  is  considerable,  but  is  insufficient  to 
prevent  the  head  from  traversing  the  brim.  At  first,  there  is 
merely  an  exaggeration  of  the  normal  process  of  moulding,  but 
as  this  exaggeration  becomes  more  marked,  laceration  of  the 
intracranial  sinuses  may  occur,  with  accompanying  haemorrhage. 
In  extreme  cases,  fracture  of  the  cranial  bones  may  result. 
The  particular  shape  which  the  head  takes  as  a  result  of  this 
moulding  depends  on  the  particular  variety  of  contracted  pelvis, 
and  will  be  discussed  in  another  place. 

A  third  consequence  of  compression  is  the  formation  of 
pressure  marks  on  the  skin  and  cranial  bones.  Whenever  the 
head  is  driven  against  or  forcibly  past  any  projection  on  the 
pelvic  wall,  the  skin  will  be  excoriated  and  perhaps  cut  by  the 
projection,  and  there  may  be  a  corresponding  dinting  of  the  sub- 
jacent cranial  bones.  As  a  rule,  the  promontory  furnishes  the 
projection,  but,  more  rarely,  it  may  consist  of  an  exostosis  on  the 
back  of  the  symphysis  pubis  or  elsewhere.  The  marking  caused 
by  the  promontory  differs  according  to  the  particular  variety  of 
contracted  pelvis,  and  to  the  mechanism  by  which  the  head  passes 
the  brim,  and  accordingly  will  be  more  suitably  described  when 
discussing  the  mechanism. 

(3)  The  Effect  on  the  Mechanism  of  Expulsion. — In  all  cases,  the 
mechanism  of  the  expulsion  of  the  foetus  depends  on  the  relation 


THE  SYMPTOMS  OF  CONTRACTED  PELVIS  DURING  LABOUR     729 

between  the  different  diameters  of  the  fcetal  head  and  the  different 
diameters  of  the  pelvic  brim.  If  these  two  sets  of  diameters 
preserve  their  normal  relation  to  one  another,  the  mechanism  of 
expulsion  in  vertex  presentation  is  that  described  as  the  normal 
mechanism.  If  the  relation  becomes  altered,  then  alterations 
in  the  normal  mechanism  are  met  with.  These  alterations  are, 
as  a  rule,  such  as  tend  to  bring  the  process  of  expulsion  into 
conformity  with  the  conditions  present,  and  consequently  may 
be  regarded  as  the  '  normal '  mechanism  under  these  special  con- 
ditions. Thus,  we  find  that  the  head  has  a  special  mechanism 
in  cases  of  flattened  pelvis,  another  special  mechanism  in  cases 
of  generally  contracted  pelvis,  and,  again,  another  in  cases  of 
generally  contracted  and  flat  pelvis,  and  that  the  head  has  the 
best  chance  of  passing  through  the  narrow  brim  only  when  this 
mechanism  occurs.  The  form  of  mechanism  peculiar  to  the 
different  varieties  of  contracted  pelvis  will  be  described  when 
discussing  these  forms. 

(4)  The  Effect  on  the  Uterus  and  Vagina. — Any  of  the  different 
forms  of  uterine  laceration,  which  have  been  already  described,  may 
occur  in  contracted  pelvis.  If  either  the  lower  uterine  segment  or 
the  cervix  is  nipped  between  the  descending  head  and  the  bony 
pelvis,  it  becomes  cedematous,  owing  to  the  obstructed  return 
of  blood  through  the  veins.  This  condition,  if  relieved  as  soon  as 
it  is  recognised,  is  not  of  any  great  consequence,  but,  if  allowed 
to  persist,  it  may  lead  to  serious  results.  In  the  first  place, 
an  cedematous  cervical  lip  offers  an  additional  obstruction  to 
delivery,  and  may  cause  rupture  of  the  lower  uterine  segment. 
Secondly,  the  anterior  lip,  or  even  the  entire  cervical  ring,  may 
be  torn  off  by  the  descending  head.  In  the  third  place,  the 
portion  of  cervical  tissue  which  is  nipped  may  slough,  and  a 
fistula  result.  Besides  these  consequences  of  nipping,  the  uterus 
may  rupture  in  its  lower  segment  as  a  result  of  the  additional 
obstruction  offered  to  delivery  by  the  pelvic  contraction. 

Laceration  and  sloughing  of  the  vagina  may  also  occur  in  cases 
in  which  the  head  has  passed  the  brim.  Lacerations  may  be  the 
result  of  an  extension  of  a  cervical  tear  into  the  posterior  fornix, 
and  sloughing  and  the  subsequent  formation  of  fistula?  are  due  to 
the  compression  of  the  vaginal  wall  between  the  presenting  head 
and  the  bony  pelvis.  As  a  rule,  such  fistula?  form  between  the 
bladder  and  vagina,  but  occasionally  they  form  between  the 
vagina  and  rectum. 

(5)  The  Post-partum  Effects  of  Pelvic  Contraction. — The  post- 
partum effects  of  pelvic  contraction  are  due  to  the  length  of 
labour,  the  bruising  and  laceration  the  soft  parts  undergo,  and 
the  intra-pelvic  manipulations  that  are  necessary.  They  consist 
chiefly  of  an  increased  tendency  to  post-partum  haemorrhage,  due 
to  the  long-continued  labour  and  consequent  exhaustion  of  the 
uterine  muscle  ;  of  an  increased  liability  to  sapraemic  and  septic 
infection,  due  to  the  lowered  resistance  of  the  tissues  brought 


730  THE  PATHOLOGY  OF  LABOUR 

about  by  their  bruising,  to  the  stagnation  of  liquor  amnii  in  the 
vagina,  and  to  the  necessary  intra-pelvic  manipulations ;  and  of 
the  formation  of  fistulae,  due  to  the  nipping  of  the  soft  parts. 

The  General  Treatment  of  Contracted  Pelvis. 

We  shall  here  discuss  briefly  the  general  principles  of  the 
treatment  applicable  to  the  common  forms  of  contracted  pelvis, 
and,  subsequently,  we  shall  discuss  the  special  treatment  to  be 
adopted  in  each  particular  form.  As  we  have  already  men- 
tioned, in  the  common  forms  of  contracted  pelvis  four  degrees  of 
contraction  are  recognised.  In  the  first  degree,  the  conjugate 
measures  from  4  to  3^  inches  in  flat  pelvis,  or  from  4  to  3J  inches 
in  generally  contracted  pelvis.  This  degree  of  contraction  is  not 
sufficient  to  prevent  the  passage  of  a  fully-formed  infant  through 
the  pelvis  under  otherwise  favourable  circumstances,  and  conse- 
quently does  not,  as  a  rule,  necessitate  operative  interference. 
One  of  two  lines  of  treatment  may  be  adopted : — either  the 
expulsion  of  the  fcetus  may  be  left  entirely  to  Nature  until  the 
head  has  passed  through  the  site  of  the  pelvic  narrowing  ;  or 
podalic  version  may  be  performed,  and  the  foetus  extracted  as  a 
pelvic  presentation. 

The  first  of  these  lines  of  treatment  allows  the  head  to  mould 
through  the  brim,  and  to  follow  whatever  particular  mechanism 
is  most  suited  to  the  form  of  contraction  present.  It  may,  how- 
ever, fail  to  effect  delivery  in  consequence  of  the  uterine  con- 
tractions being  insufficiently  strong  to  overcome  the  resistance 
present.  In  such  cases,  the  application  of  the  forceps  will 
supplement  the  natural  force  supplied  by  the  contractions  of 
the  uterus,  and  so  will  sometimes  enable  a  head  to  overcome  a 
resistance  which  it  could  not  have  overcome  when  alone  driven 
down  by  the  uterine  contractions.  The  application  of  the  forceps 
has,  however,  the  disadvantage  that,  if  the  head  is  not  fixed  in 
the  brim,  the  control,  which  the  forceps  exercises  over  the  pre- 
senting head,  prevents  the  latter  from  following  the  particular 
mechanism  suited  to  the  nature  of  the  contraction,  and  also,  as 
will  be  seen,  increases  the  lateral  diameters  of  the  head.  If,  how- 
ever, the  head  has  passed  the  site  of  contraction,  the  forceps  does 
not  tend  to  increase  the  difficulty  of  delivery,  and  so  may  be 
more  safely  employed. 

The  second  line  of  treatment,  i.e.,  prophylactic  podalic  version, 
enables  any  required  degree  of  additional  force  to  be  supplied, 
and  also  allows  us  to  take  advantage  of  the-  natural  shape  and 
formation  of  the  head.  When  the  head  of  the  fcetus  presents 
and  is  dragged  down  against  a  narrow  brim  by  the  forceps,  the 
combined  effect  of  the  resistance  offered  by  the  brim  to  the 
descent  of  the  head  and  of  the  downward  traction  applied  to  the 
base  of  the  skull  by  the  forceps,  is  to  cause  a  lateral  bulging  of 
the  cranial  walls,  and  so  an  increase  in  the  lateral  diameters  of 


GENERAL  TREATMENT  OF  CONTRACTED  PELVIS 


73i 


the  head,  the  disproportion  between  the  head  and  the  narrow 
brim  being  thus  increased.  The  effect  of  this  is  well  shown  in 
the  diagram  (v.  Fig.  301).  When,  on  the  other  hand,  the  foetus 
is  extracted  as  a  pelvic  presentation  and  the  head  comes  last, 
the  base,  or  narrow  part  of  the  head,  enters  the  brim  first  and 
the  wider  portions  follow,  the  head  thus  resembling  a  wedge 
driven  down  into  the  brim.  The  result  of  this  is  that  the  narrow 
brim,  instead  of  causing  an  increase  in  the  lateral  diameters  of 
the  head,  causes  a  diminution,  as  each  successive  diameter  as  it 
comes  down  is  compressed  laterally,  and  consequently  the  dis- 
proportion between  the  head  and  the  narrow  brim  is  lessened 
and  not  increased  by  traction,  as  in  the  former  case.  Further- 
more,  the  head  can  be  brought    through  the  pelvis   in  such  a 


Fig.  301. — The  Change  of  Shape  that  occurs  in,  A,  the  Presenting 
Head,  and,  B,  the  After-coming  Head,  when  Compressed  by  the 
Brim  of  a  Contracted  Pelvis. 

The  firm  outline  is  that  of  the  unmoulded  head,  the  dotted  outline  that  of 
the  moulded  head. 


manner  that  its  longest  diameters  correspond  to  the  longest 
diameters  of  the  pelvis,  and  full  advantage  can  be  taken  of  the 
temporary  increase  in  size  of  the  pelvic  brim  which  is  obtained 
by  placing  the  patient  in  Walcher's  position.  The  patient  can 
readily  remain  in  this  position  for  the  short  time  necessary  for 
the  extraction  of  an  after-coming  head,  but  it  is  impossible  to 
keep  her  in  such  a  position  during  the  varying  number  of  hours 
that  the  fore-coming  head  takes  to  mould  through  the  brim. 
The  gross  gain  in  the  length  of  the  true  conjugate  obtained  by 
Walcher's  position  is  about  one  centimetre  or  two-fifths  of  an 
inch,  and  this  is  often  of  considerable  value. 

Prophylactic  version  has,  however,  also  certain  disadvantages 


732  THE  PATHOLOGY  OF  LABOUR 

attaching  to  its  use.  When  the  head  of  the  fcetus  comes  first,  it  can 
take  an  indefinite  period,  comparatively  speaking,  to  pass  through 
the  brim,  as  there  is  not  necessarily  any  interference  with  the 
circulation  in  the  umbilical  vessels.  When,  however,  the  head 
comes  last,  it  cannot  be  allowed  to  take  more  than  two  minutes  to 
pass  through,  as  during  the  entire  time  it  is  passing  through  the 
pelvic  cavity  the  umbilical  cord  is  being  compressed  and  circula- 
tion in  it  checked.  Therefore,  delivery  must  be  very  rapidly 
effected,  or  else  the  object  with  which  the  line  of  treatment  has 
been  adopted,  i.e.,  the  preservation  of  the  life  of  the  foetus,  is  not 
attained.  As  we  shall  subsequently  see,  prophylactic  version  is 
only  applicable  to  cases  of  flattened  pelvis,  as,  in  generally  con- 
tracted pelvis,  the  diminished  transverse  diameter  of  the  pelvis 
prevents  the  long  antero-posterior  diameters  of  the  head  from 
finding  room,  and  also  tends  to  bring  about  extension  of  the  head 
— an  occurrence  which  would  be  fatal  to  the  life  of  the  foetus. 
Version  performed  in  suitable  cases,  and  by  a  capable  obstetrician, 
is  a  valuable  procedure,  and  improves  the  prognosis  for  both 
mother  and  foetus.  Version  performed  in  an  unsuitable  case, 
in  which  the  subsequent  delivery  of  the  unmutilated  foetus  is 
impossible,  greatly  increases  the  difficulty  of  effecting  delivery, 
for,  while  the  perforation  and  extraction  of  the  presenting  head  is 
a  comparatively  easy  matter,  the  same  procedure  in  the  case  of 
an  after-coming  head  may  be,  and  usually  is,  most  difficult. 

Accordingly,  we  see  that  each  line  of  treatment  presents  certain 
advantages  and  certain  disadvantages.  Allowing  the  head  to 
mould  through  the  brim  is  a  satisfactory  procedure,  if  the  dis- 
proportion is  not  too  great,  and  if  the  uterine  contractions  are 
of  their  normal  strength.  If  the  latter  are  not  of  their  normal 
strength,  the  application  of  the  forceps  is  useful  after  the  head 
has  passed  the  brim,  and  even  in  cases  in  which  the  head  has 
not  passed  the  brim  it  may  sometimes  be  successful.  Prophy- 
lactic version  is  useful  in  flattened  pelves.  If  it  is  selected  as  the 
line  of  treatment,  external  version  should  be  performed  as  soon 
as  the  os  is  sufficiently  dilated  to  admit  two  or  three  fingers,  and 
a  foot  be  drawn  down  in  order  to  minimise  the  risk  of  impaction 
of  the  breech  in  the  pelvis  and  to  give  something  on  which  we 
can  apply  traction  if  necessary.  If  the  premature  rupture  of  the 
membranes  prevents  the  performance  of  external  version,  internal 
version  must  be  performed  as  soon  as  the  uterine  orifice  is 
sufficiently  dilated  to  allow  the  introduction  of  the  hand.  If  we 
decide  to  allow  the  head  to  mould  through  the  brim,  the  case 
must  be  closely  watched  through  the  whole  labour,  and  delivery 
immediately  effected  if  the  symptoms  of  threatened  rupture  of  the 
uterus  appear. 

It  is  customary  in  many  text-books  to  labour  at  a  comparison 
between  the  application  of  the  forceps  and  prophylactic  version, 
as  two  competing  lines  of  treatment  in  this  degree  of  contracted 
pelvis.     We  confess,  however,  that  we  consider  it  a  mistake  to 


GENERAL  TREATMENT  OE  CONTRACTED  PELVIS  733 

force  a  comparison.  These  two  methods  are  in  no  sense  com- 
peting methods.  In  the  first  place,  the  application  of  the  forceps 
cannot  be  truly  regarded  as  a  distinct  line  of  treatment.  It  is  an 
adjunctory  treatment,  which  is  adopted  as  a  last  resource  in  cases 
in  which  the  head  has  been  left  to  mould  through  the  brim,  but 
in  which  the  uterine  contractions  are  not  sufficiently  strong  to 
bring  the  head  through.  It  should  never  be  adopted  until  mould- 
ing fails,  as  in  the  great  proportion  of  cases  the  latter  offers  a 
better  prospect  of  success.  In  the  second  place,  in  cases  in  which 
the  application  of  the  forceps  is  advisable,  version  is  contra- 
indicated,  because  the  patient  has  been  for  a  long  time  in  labour, 
and  the  condition  of  the  uterine  muscle  forbids  such  intra-uterine 
manipulation.  Some  writers,  notably  Galabin,*  regard  the  rela- 
tive position  of  the  forceps  and  version  in  a  different  light. 
Galabin  considers  that  once  the  existence  of  any  considerable 
degree  of  contraction  is  recognised,  the  application  of  the  forceps 
should  not  be  long  delayed,  and  that  if  it  fails  to  effect  delivery 
version  may  be  then  performed.  He  supports  his  view  by 
statistics  which  show  that,  after  forceps  application,  88'  1  per  cent, 
of  children  were  born  alive,  and  after  version  71  "4.  If,  however, 
version  was  only  adopted  in  cases  in  which  the  forceps  had 
already  failed,  it  is  obvious  that  71-4  per  cent,  cannot  be  regarded 
as  the  true  percentage  of  living  children  that  can  be  obtained  by 
prophylactic  version,  since  many  of  the  deaths  must  have  been  the 
result  of  ineffectual  efforts  at  delivery  by  the  forceps.  Further- 
more, the  writer  in  question  in  his  comparison  does  not  appear  to 
distinguish  sufficiently  between  cases  of  flattened  and  of  generally 
contracted  pelvis. 

There  is,  of  course,  another  line  of  treatment  which  can  be 
adopted  in  all  cases.  As,  however,  it  is  never  the  treatment  of 
choice  and  is  only  adopted  under  compulsion  or  in  the  case  of  the 
death  of  the  foetus,  we  have  not  included  it  with  the  others.  It  is 
the  performance  of  craniotomy,  an  operation  which  is  necessary 
when  other  procedures  fail.  If,  however,  we  have  diagnosed 
the  nature  and  degree  of  the  contraction  correctly,  craniotomy 
should  rarely  or  never  be  required,  since,  when  delivery  by 
one  of  the  foregoing  methods  is  impossible,  Cesarean  section 
or  symphysiotomy  should  be  performed.  To  be  compelled 
to  perform  craniotomy  as  a  last  resource  is  a  tacit  confession 
that  for  some  reason  or  other  we  have  failed  in  the  treatment 
of  the  case.  In  practice,  however,  accurate  diagnosis  is  at  times 
impossible,  as  the  actual  size  and  hardness  of  the  foetal  head  are 
factors  which  it  is  difficult  to  estimate  correctly,  and,  if  our 
measurements  show  that  we  are  dealing  with  a  contraction  of 
the  first  degree,  we  can  only  adopt  the  measures  which  have 
been  proved  to  be  usually  successful  in  that  degree,  and  fall 
back  on  craniotomy  if  they  fail.  The  advice  of  Spiegelberg, 
founded  on  his  great  experience,  is  well  worthy  of  being  repro- 

*  Op.  cit.,  p.  543. 


734 


THE  PATHOLOGY  OF  LABOUR 


duced,  and  though  it  must  perhaps  be  slightly  modified  to  suit 
conditions  other  than  those  under  which  he  practised,  it  is  very 
doubtful  if  it  can  be  improved : — '  When,  and  so  long  as,  the 
spontaneous  passage  of  the  head  appears  to  be  possible  and  free 
from  danger,  wait.  When  the  condition  of  the  mother  forbids 
any  further  delay,  perforate  and  extract  with  the  cranioclast,  if 
the  head  is  still  high  ;  apply  the  forceps,  if  the  region  of  the 
contraction  has  been  passed,  and  the  child  is  alive.  .  .  .  The 
life  of  the  child  must  always  be  of  little  weight  in  comparison 
with  that  of  the  mother  ;  every  operative  interference  involves 
great  risk  for  it,  and  its  prospects  are  on  the  whole  best  when 
labour  takes  its  own  course.'  The  modification,  which  altered 
conditions  of  practice  may  necessitate,  is  to  be  found  in  the  use 
of  the  forceps  when  the  head  is  not  fixed,  and  when  the  condition 
of  the  mother  forbids  further  delay.  It  is  extremely  improbable 
that  in  cases  of  flattened  pelvis  the  foetus  will  be  saved  by  so 
doing,  but  if  even  the  slightest  chance  of  life  is  afforded  by  the 
use  of  the  forceps  many  obstetricians  will  consider  that  it  is  their 
duty  to  use  it.  In  generally  contracted  pelvis,  on  the  other  hand, 
the  application  of  the  forceps  may  be  often  successful,  and,  as 
the  diagnosis  of  the  exact  form  of  contraction  present  is  often 
uncertain,  it  follows  that  in  all  cases  the  forceps  will  be  given 
a  trial  when  the  condition  of  the  mother  forbids  further  delay, 
whether  the  head  is  or  is  not  fixed,  provided  that  the  foetus  is 
alive.  If  it  fails  to  effect  delivery,  craniotomy  must  be  then 
performed. 

In  the  second  degree  of  pelvic  contraction,  the  conjugate 
measures '  from  3^  to  2f  inches  in  flattened  pelves,  or  from  3^ 
to  3  inches  in  generally  contracted  pelves.  In  this  degree,  the 
expulsion  of  a  fully-formed  foetus  by  the  natural  efforts  or  its 
extraction  by  the  forceps  may  be  regarded  as  impossible.  If 
the  case  is  seen  sufficiently  early  in  pregnancy,  the  ideal  mode 
of  treatment  consists  in  the  induction  of  premature  labour,  a 
procedure  which  may  also  be  adopted  with  advantage  in  cases 
of  narrowing  of  the  first  degree  in  which  previous  efforts  to 
obtain  a  living  foetus  by  the  procedures  just  recommended  have 
proved  unsuccessful.  If  the  case  is  seen  too  late  to  induce 
premature  labour,  and  if  a  living  child  is  to  be  obtained,  prophy- 
lactic version,  symphysiotomy,  or  Csesarean  section  must  be 
performed.  The  most  important  point  in  the  induction  of  pre- 
mature labour  is  the  determination  of  the  correct  date  at  which  to 
induce  it.  If  labour  is  induced  too  early,  the  fcetus  is  more 
immature  than  is  necessary,  and  consequently  the  difficulty  of 
rearing  it  is  greater.  If  labour  is  induced  too  late,  the  foetus  may 
be  too  large  to  pass  through  the  brim,  and  consequently  the 
operation  has  been  undertaken  for  nothing.  The  date  at  which 
to  induce  labour  can  be  ascertained  in  two  ways.  The  first 
is  the  more  theoretical,  and  consists  in  ascertaining  the  exact 
duration  of  pregnancy  and  the  average  size  of  the  foetal  head  at 


GENERAL  TREATMENT  OF  CONTRACTED  PELVIS 


735 


the  different  weeks,  and  in  then  inducing  labour  during  the  last 
week  at  which  we  consider  that  a  head  of  average  size  can  pass 
through  the  pelvis  with  which  we  are  dealing.  The  following 
table  shows  the  week  at  which  labour  should  be  induced  in 
accordance  with  the  size  of  the  true  conjugate  in  a  flattened 
and  in  a  generally  contracted  pelvis  : — 


Length  of  Conjugate  in 
Flat  Pelvis. 

Length  of  Conjugate  in 
Generally  Contracted  Pelvis 

Time  to  induce 
Labour. 

2f  ins.  (7  cms.) 
3      ,,     (7-5  cms.) 
3i    -.     (8'25  cms.) 
3I    „     (9  cms.) 

3    ins.  (7-5  cms.) 
3i    -.     (8-25  cms.) 
3|   ,,     (gems.) 
3l    ■■     (9  "5  cms.) 

28th  week. 
30th      ,, 
32nd 
34th      ,, 

This  method  of  ascertaining  the  date  is  unsatisfactory,  as  it  is 
impossible  to  estimate  the  exact  age  of  pregnancy,  and  even  if 
this  can  be  done,  the  method  takes  no  account  of  the  varying 
sizes  of  the  fcetal  head  at  similar  periods  of  pregnancy.  It  is 
useless  to  induce  labour  before  the  twenty-eighth  week  as  the 
foetus  would  be  immature,  or  after  the  thirty-sixth  week,  as  from 
that  date  onwards  there  is  little  or  no  increase  in  the  size  of  the 
fcetal  head,  and  consequently  induction  of  labour  will  not  make 
delivery  any  easier. 

The  second  method  was  introduced  by  Miiller*  and  Schatz,t  and 
is  more  satisfactory  than  the  foregoing.  It  consists  in  attempts, 
made  from  time  to  time,  to  push  the  head  of  the  foetus  into  the 
pelvic  brim.  The  first  attempt  is  made  in  or  about  the  twenty- 
seventh  week  as  nearly  as  we  can  guess,  and  is  repeated  every 
six  to  eight  days.  The  patient  is  placed  in  the  cross-bed  position 
or  on  a  gynaecological  couch,  and  the  obstetrician  passes  two 
fingers  into  the  vagina  and  upwards  until  they  touch  the  pre- 
senting head.  The  head  is  then  grasped  with  the  left  hand,  the 
fingers  over  the  occiput,  and  the  thumb  over  the  chin,  or  vice 
versd,  according  to  the  position  of  the  foetus,  and  is  pressed  into 
the  brim,  while  an  assistant  supplements  this  force  by  also 
pressing  down  with  both  his  hands  superimposed  on  those  of 
the  operator  (v.  Fig.  302).  So  long  as  it  is  possible  to  push  the 
greatest  diameter  of  the  head  through  the  brim,  it  is  too  soon  to 
induce  labour,  but  the  first  day  we  are  unable  to  do  this  labour 
may  be  induced.  The  contractions  of  the  uterus  can  drive 
through  the  brim  a  head  which  could  not  be  pushed  through  in 
the  manner  described. 

If  the  patient  is  not  seen  until  pregnancy  is  too  far  advanced  to 
permit  the  induction  of  labour,  delivery  may  sometimes  be  effected, 

*  '  Ueber  die  Prognose  der  Geburt  bei  engen  Becken,'  Archiv.  f.  Gyn.,  1896, 
vol.  xxvii. ,  p.  311. 

f  Centvalbl.  f.  Gyniik.,  1885,  vol.  ix.,  p.  660. 


736  THE  PATHOLOGY  OF  LABOUR 

in  the  case  of  flattened  pelves,  if  prophylactic  version  is  performed, 
and  the  patient  placed  in  Walcher's  position  during  the  extraction 
of  the  head.  The  adoption  of  this  treatment  by  any  but  a 
skilled  obstetrician  with  the  necessary  assistance  at  hand  cannot 
be  recommended  in  cases  in  which  the  conjugate  is  below  three 
inches.  The  difficulty  of  extracting  the  head  through  a  smaller 
brim  is  so  considerable  that  there  is  but  little  chance  of  obtaining 
a  living  foetus,  and  there  is  considerable  risk  of  bringing  about 


Fig.  302. — Muller's  Method  of  ascertaining  the  Date  at  which 
to  Induce  Labour. 

O  O,  Operator's  hands;   A  A,  assistant's  hands. 

impaction  of  the  head  and  so  necessitating  the  performance  of 
perforation — always  a  difficult  operation  in  these  cases.  A  skilled 
obstetrician  will  frequently  be  able  to  extract  a  living  child 
even  in  this  degree  of  contraction,  provided  that  the  child  is  not 
above  the  normal  size,  and  that  he  is  dealing  with  a  case  of 
flattened  and  not  of  generally  contracted  pelvis.  The  perform- 
ance of  prophylactic  version  in  a  generally  contracted  pelvis  of 
this  degree  would  be  a  most  inadvisable  procedure. 

If   prophylactic  version   is  deemed    to   be  inexpedient,  either 


GENERAL  TREATMENT  OF  CONTRACTED  PELVIS  737 

because  it  has  failed  to  procure  a  living  child  in  former  labours, 
or  because  the  apparent  size  of  the  foetus  or  the  nature  of  the 
contraction  contra-indicates  it,  we  must  choose  between  sym- 
physiotomy and  Cesarean  section.  Which  of  these  two  ought 
to  be  selected  depends  upon  the  previous  experience  of  the 
operator,  and  the  circumstances  under  which  the  case  is  operated 
upon.  If  the  obstetrician  possesses  a  knowledge  of  the  method 
of  performing  the  operation,  if  he  has  sufficient  assistance,  and 
if  the  patient  is  sure  of  skilled  nursing  subsequently,  symphysio- 
tomy presents  certain  advantages.  On  the  other  hand,  Caesarean 
section  is  an  easier  operation,  and  can  be  performed  in  an  emer- 
gency with  a  minimum  of  assistance.  Moreover,  its  technique 
and  prognosis  have  been  so  improved  of  late  years  that  it  is  no 
longer  the  formidable  operation  it  was  previously  considered  to 
be.  If  symphysiotomy  is  chosen,  it  should  be  performed  as 
soon  as  the  uterine  orifice  has  reached  a  sufficient  size  to  permit 
the  passage  of  the  foetus.  If  the  premature  rupture  of  the  mem- 
branes prevents  the  dilatation  of  the  orifice,  dilatation  must  be 
effected  by  dilators  or  by  incision.  As  soon  as  the  symphysis  has 
been  divided,  the  foetus  is  extracted  with  the  forceps,  or,  version 
having  previously  been  performed,  as  a  pelvic  presentation.  If 
Caesarean  section  is  selected,  the  operation  should  be  performed, 
if  possible,  prior  to  the  rupture  of  the  membranes,  but  not  until 
the  uterine  orifice  is  sufficiently  dilated  to  allow  the  subsequent 
free  escape  of  the  lochia. 

If  prophylactic  version  is  considered  unsuitable,  and  if  the  cir- 
cumstances of  the  case  forbid  the  performance  of  Caesarean  section 
or  symphysiotomy,  there  is  no  other  course  open  save  craniotomy. 
This  operation  is  adopted  as  a  matter  of  course  in  all  cases 
in  which  the  foetus  is  dead,  but  is  rarely  required  at  the  present 
time  when  the  foetus  is  living,  as  the  advance  in  obstetrical 
knowledge  and  technique  has  provided  us  with  the  means  of 
saving  the  life  of  both  mother  and  child  in  almost  every  case. 
Many  obstetricians  hesitate  to  perform  craniotomy  on  a  living 
foetus  even  when  there  is  no  alternative,  and  many  more  are 
forbidden  to  do  so  by  their  religious  convictions.  It  is  unneces- 
sary to  enter  at  any  length  into  the  permissibility  of  the  operation, 
and  it  is  sufficient  to  say,  first,  that  it  is  only  when  all  other 
means  of  effecting  delivery  are  impossible  that  it  is  permissible  ; 
secondly,  that  in  the  large  majority  of  such  cases  the  foetus  is  no 
longer  living  when  craniotomy  is  actually  performed,  and  that 
hence  the  necessity  for  perforating  a  living  foetus  is  extremely 
rare  ;  and,  lastly,  that,  in  those  cases  in  which  the  perforation  of 
a  living  child  is  necessary,  it  must  be  remembered  that  we  have 
to  make  a  choice  between  the  destruction  of  the  foetus  and  the 
destruction  of  both  mother  and  foetus ;  that,  in  other  words,  it 
is  not  a  case  of  saving  the  foetus  at  the  cost  perhaps  of  the 
mother's  life,  but  of  losing  the  life  of  the  latter  without  in  any 
way  benefiting  the  former. 

47 


738  THE  PATHOLOGY  OF  LABOUR 

In  the  third  degree  of  contraction,  the  conjugate  measures  from 
2|  to  i\  inches  in  flattened  pelvis,  or  from  3  to  2^  inches  in 
generally  contracted  pelvis,  but  this  degree  of  narrowing  is  rarely 
met  with  in  the  latter  form  of  pelvis.  It  is  sufficient  to  prevent 
the  passage  through  the  pelvis  of  even  a  premature  foetus  unless 
reduced  in  size  by  craniotomy,  and  even  symphysiotomy  will  not 
afford  sufficient  space  for  the  passage  of  a  full-term  foetus.  Con- 
sequently, if  the  life  of  the  latter  is  to  be  saved,  Caesarean  section 
must  be  performed.  If  the  conditions  of  the  case  forbid  the  per- 
formance of  Caesarean  section,  or  if  the  foetus  is  dead,  craniotomy 
must  be  performed. 

In  the  fourth  degree  of  pelvic  contraction,  the  conjugate 
measures  7.\  inches  or  less  in  flattened  pelvis,  or  i\  inches  or  less 
in  generally  contracted  pelvis,  but  it  is  doubtful  if  this  degree  of 
narrowing  is  ever  met  with  in  the  latter  class  of  deformity. 
This  degree  is  known  as  absolute  pelvic  contraction,  and,  in  it, 
the  disproportion  between  the  head  and  the  pelvis  is  such  that 
it  is  impossible  to  bring  even  a  mutilated  foetus  through  the 
pelvic  cavity,  consequently  in  all  these  cases  Caesarean  section 
must  be  performed. 

Prognosis. — The  prognosis  for  both  mother  and  foetus  is  always 
serious  in  contracted  pelvis.  While  the  severe  degrees  of  con- 
traction expose  the  mother  to  all  the  dangers  attendant  on  the 
performance  of  a  major  operation,  the  slight  degrees  expose  her 
to  the  risks  that  necessarily  attend  a  long  labour,  frequent  vaginal 
examinations  and  manipulations,  and  severe  bruising  of  the  soft 
tissues.  Spiegelberg  estimated  that  the  average  maternal  mortality 
in  all  cases  in  which  pelvic  contraction  was  present  amounted  to 
about  7-9  per  cent.,  and  the  fcetal  mortality  to  32  per  cent. 
Amongst  the  common  forms  of  contraction — generally  contracted 
pelvis,  flat  pelvis,  and  generally  contracted  flat  pelvis,  the 
prognosis  for  both  mother  and  foetus  is  best  in  the  generally 
contracted  pelvis,  and  the  mortality  has  been  estimated  at  6*8  per 
cent,  for  the  mother,  and  9/5  per  cent,  for  the  foetus.  In  the  flat 
pelvis,  the  maternal  mortality  is  estimated  at  77  per  cent.,  the 
foetal  mortality  at  60  per  cent.  In  the  generally  contracted  flat 
pelvis,  the  mortality  both  for  mother  and  foetus  is  worst,  and  is 
estimated  at  8-3  per  cent,  for  the  mother,  and  at  66  per  cent,  for 
the  foetus.  These  figures  are  given  by  Winckel  and  Litzmann  ; 
if  they  are  correct  the  average  foetal  mortality  of  32  per  cent,  in 
.all  cases  of  deformity  given  by  Spiegelberg  is  too  low. 


CHAPTER  III 
THE  COMMON  FORMS  OF  CONTRACTED  PELVIS 

Generally  Contracted  Pelvis  —  Rachitic  —  Non-rachitic  —  Dwarf.  Flattened 
Pelvis — The  Flat  Pelvis,  Non-rachitic,  Rachitic — The  Generally  Con- 
tracted Flat  Pelvis,  Non-rachitic,  Rachitic— Pelvis  of  Congenital  Dis- 
location of  the  Hips. 

The  common  forms  of  contracted  pelvis  are  met  with  in  the  first 
two  classes  of  the  classification  we  have  adopted.  These  groups 
are  as  follows  : — 

I.  Generally  contracted  pelvis, 
(i)  Generally  contracted  pelvis. 

(a)  Non-rachitic. 

(b)  Rachitic. 
(2)   Dwarf  pelvis. 

II.   Flattened  pelvis. 

(1)  Flat  pelvis. 

(a)  Non-rachitic. 

(b)  Rachitic. 

(2)  Generally  contracted  flat  pelvis. 

(a)  Non-rachitic. 

(b)  Rachitic. 

(3)  Pelvis  of  congenital  dislocation  of  hips. 

Of  the  different  varieties  of  pelvis  included  in  these  two  classes, 
only  four  can  be  regarded  as  common.     These  are  as  follows  :  — 

I.  (1)  (a)  The  generally  contracted  non-rachitic  pelvis. 

II.  (1)  The  flat  pelvis,  both  non-rachitic  and  rachitic. 
(2)  (b)  The  generally  contracted_,flat  rachitic  pelvis. 

As,  however,  the  other  and  rare  varieties  included  in  Classes  I. 
and  II.  are  so  similar  to  the  common  varieties,  both  anatomically 
and  in  their  effect  upon  labour,  we  shall  discuss  all  the  varieties 
met  with  in  Classes  I.  and  II.  in  the  same  chapter. 


739  47—2 


74Q 


THE  PATHOLOGY  OF  LABOUR 


Generally  Contracted  Pelvis. 

A  generally  contracted  pelvis,  a  small  round  pelvis,  or  a  pelvis 
aquabiUiev  justo -minor,  are  the  terms  applied  to  a  pelvis  in  which 
all  the  diameters  are  smaller  than  normal,  but  still  preserve  their 
normal  relation  to  one  another. 

Varieties. — The  following  varieties  of  generally  contracted  pelvis 
are  met  with  : — 

(i)  Generally  contracted  pelvis. 

(a)  Non-rachitic. 

(b)  Rachitic. 
(2)  Dwarf  pelvis. 


Fig.   303. — The  Generally  Contracted  Non-rachitic  Pelvis  * 

Frequency.—  All  the  varieties  of  generally  contracted  pelvis  are 
less  common  than  are  those  of  flattened  pelvis,  and  the  only 
variety  which  can  be  regarded  as  at  all  common  is  the  generally 
contracted  non-rachitic  pelvis.  The  generally  contracted  rachitic 
pelvis  is  extremely  rare,  as  rickets  almost  invariably  tends  to 
produce  pelvic  flattening.  The  dwarf  pelvis  is  also  of  extreme 
rarity.  According  to  Winckel's  statistics,  generally  contracted 
pelvis  and  generally  contracted  flat  pelvis  taken  together  con- 
stitute only  1-67  per  cent,  of  all  pelvic  deformities. 

Generally  Contracted  Pelvis. — Although  in  our  classifica- 
tion we  have  divided  this  form  of  pelvis  into  non-rachitic  and 

*  The  set  of  drawings  of  contracted  pelvis  in  this  and  the  next  chapter 
were  specially  made  for  this  book  from  the  collection  of  the  late  Professor 
Milne  Murray,  of  Edinburgh,  who  had  devoted  much  time  and  labour  to 
the  perfecting  of  it. 


THE  GENERALLY  CONTRACTED  PELVIS  741 

rachitic,  it  is  more  convenient  to  discuss  both  varieties  together, 
since  they  are  very  similar  in  conformation  ;  and,  apart  from  the 
history  of  the  individual  and  from  such  general  signs  of  mild 
rickets  as  may  be  found  in  other  parts  of  the  skeleton,  it  is  almost 
impossible  to  distinguish  them  in  the  living. 

The  generally  contracted  pelvis  is  most  commonly  found  in 
women  below  the  average  size,  and  is  then  in  keeping  with  the 
general  skeletal  development.  It  has  also  been  occasionally 
observed  in  women  of  normal  or  even  of  large  size,  especially  in 
those  whose  general  form  approaches  the  masculine  type.  It 
presents  the  appearance  of  a  normal  female  pelvis,  in  which  all 
the  diameters  are  diminished  in  length.  This  diminution  is 
usually  so  proportioned  that  the  diameters  retain  their  normal 
relation    to   one   another.     Sometimes,   the    shortening   is    more 


A  B 

Fig.  304. — The  Generally  Contracted  Non-rachitic  Pelvis. 

A,  Outline  of  the  brim  ;  B,  sagittal  section.    (Outline  of  normal  pelvis  in 
black,  of  contracted  pelvis  in  red.) 

marked  in  one  diameter  than  in  another,  most  frequently  in  the 
conjugata  vera,  and  produces  in  such  a  case  a  condition  which 
approximates  to  the  generally  contracted  flat  pelvis,  and  which 
is  usually  the  result  of  mild  rickets  (rachitic  variety).  Further 
evidence  of  this  disease  may  possibly  be  found  in  extreme  pro- 
minence of  the  ilio-pectineal  lines. 

The  cause  of  contraction  in  non-rachitic  cases  is  unknown,  but 
the  deformity  has  been  ascribed  to  the  carrying  of  heavy  weights 
in  childhood,  thus  throwing  an  excessive  strain  upon  the  pelvis, 
or  to  such  general  diseases  as  anaemia,  which  may  produce  a 
universal  arrest  of  development. 

There  is  a  variety  of  the  justo-minor  pelvis  which  is  called  the 
infantile  or  juvenile  form,  because  it  retains  the  characteristics  of 
the  pelvis  found  in   children.     In  these  cases,  development  has 


742  THE  PATHOLOGY  OF  LABOUR 

followed  a  normal  course  up  to  a  certain  period,  but  has  then 
ceased  from  some  unknown  cause.  The  narrowing  in  this  form 
may  be  extreme,  but  is  very  irregular,  and  often  most  marked  at 
the  outlet.  The  sacrum  is  narrow,  and  its  lateral  masses  are  ill- 
developed.  It  retains  its  position  far  back  between  the  iliac 
bones,  and  the  promontory  lies  at  a  relatively  high  level,  so  that 
the  inlet  is  somewhat  oval  in  shape,  the  transverse  diameter  being 
more  contracted  than  the  antero-posterior.  The  position  of  the 
sacrum,  and  the  fact  that  its  vertical  curvature  is  rather  less 
than  normal,  make  it  appear  as  if  the  weight  of  the  trunk  had 
been  unable  to  produce  its  usual  effects  during  growth,  perhaps 
on  account  of  premature  consolidation  of  the  sacral  vertebrae.* 

The  Dwarf  Pelvis. — The  dwarf  pelvis,  or  pelvis  nana,  is  most 
often  the  result  of  a  severe  type  of  rickets,  or  some  similar 
disease  of  the  bones,  occurring  either  in  foetal  or  in  early  extra- 
uterine life,  and  causing  a  general  cessation  of  development  of 


Fig.  305. — The  Generally  Contracted  Pelvis.     The  Dwarf  Pelvis. 

the  body.  It  occurs  in  true  dwarfs,  in  whom  a  cause  for  their 
small  size  cannot  be  detected.  The  bones  are  slight  and  often 
remain  united  by  cartilage,  and  the  contraction,  as  a  rule,  is 
extreme  throughout  the  whole  canal. 

Symptoms. — We  have  already  referred  to  the  symptoms  of 
contracted  pelvis  which  are  common  to  all  forms  of  contraction, 
and  shall  here  alone  refer  to  those  which  are  peculiar  to  the 
special  form  with  which  we  are  dealing.  We  may  discuss  these 
special  symptoms  under  similar  headings  to  those  under  which 
we  previously  discussed  the  general  symptoms. 

(1)  Effect  on  the  Relation  of  the  Head  to  the  Brim. — As  the 
degree  of  contraction  which  is  usually  met  with  in  this  form  is 
not  so  great  as  in  flattened  pelvis,  and  as  the  brim  preserves  its 
normal  shape,  the  uterus  is  not  displaced  upwards  during  preg- 
nancy to  any  very  great  extent,  and  the  presenting  vertex  fits  the 
*  Winckel,  '  Text-book  of  Midwifery,'  p.  466. 


THE  GENERALLY  CONTRACTED  PELVIS  743 

brim  almost  as  in  normal  cases.  In  consequence  of  this,  pendulous 
abdomen  and  malpresentations  are  not  the  rule,  the  head  fills 
the  lower  segment  of  the  uterus  in  the  usual  manner,  and  the 
liquor  amnii  does  not  tend  to  escape  very  suddenly  or  completely. 
(2)  Effect  on  the  Foetus. — The  caput  succedaneum  is  of  large 
size,  and  forms  in  the  region  of  the  posterior  fontanelle.  The 
occipito-mental  diameter  of  the  head  is  greatly  elongated,  the 
head  appearing  as  if  it  had  been  drawn  out.  The  occipital  and 
frontal  bones  are  driven  under  the  parietals.  As  a  rule,  there  are 
no  definite  areas  of  compression,  resembling  the  dints  and  furrows 
which  occur  in  flattened  pelves,  inasmuch  as  the  pressure  on  the 
head  is  fairly  uniform,  but  ecchymoses  and  red  patches,  due  to 
the  pressure  of  the  promontory,  occasionally  occur.  The  most 
characteristic  mark  is  said  to  be  a  red  stripe,  running  from  the 


A  B 

Fig.  306. — The  Dwarf  Pelvis. 

A,  Outline  of  brim  ;  B,  sagittal  section.     (Outline  of  normal  pelvis  in 
black,  of  contracted  pelvis  in  red.) 

parietal  bone  towards  the  eye  or  upper  jaw,  and  caused  by  the 
pressure  of  the  promontory. 

(3)  Effect  on  the  Mechanism  of  Expulsion. — If  the  head  is  to 
pass  through  a  pelvic  brim  all  of  whose  diameters  are  lessened, 
it  is  obvious  that  its  smallest  diameters  must  come  into  relation 
with  the  diameters  of  the  brim.  Accordingly,  we  find  that 
the  degree  of  flexion  is  very  much  more  marked  than  it  is  under 
normal  circumstances,  and  that  the  posterior  fontanelle  presents 
at  the  brim.  This  increased  flexion  is  due  to  the  increased 
resistance  to  the  descent  of  the  head  ;  the  greater  the  degree  of 
contraction,  the  more  marked  it  is,  and  in  some  cases  it  may 
proceed  so  far  that,  not  the  posterior  fontanelle,  but  the  occipital 
bone  presents.  The  head  consequently  engages  with  a  diameter 
posterior  to  the  sub-occipito-bregmatic  diameter  in  the  oblique 
diameter  of  the  pelvis,  and  in  a  synclitic  manner — that  is,  with 


744  THE  PATHOLOGY  OF  LABOUR 

the  line  joining  the  parietal  eminences  parallel  to  the  plane  of 
the  brim,  thus  contrasting  markedly  with  the  mode  of  engage- 
ment in  flattened  pelvis.  Once  the  head  has  passed  the  brim, 
the  remaining  mechanism  resembles  that  of  a  normal  case,  save 
that  internal  rotation  occurs  at  an  earlier  stage,  and  is  more 
complete  than  usual.  This  is  due  to  the  fact  that  obstruction  to 
the  passage  of  the  foetus  does  not  cease  as  soon  as  the  head  has 
passed  through  the  brim,  but  is  maintained  during  its  passage 
through  the  pelvic  cavity.  Consequently,  the  head  is  forced  to 
bring  its  diameters  into  as  complete  conformity  as  possible  with 
the  diameters  ox  the  brim. 

(4)  Effect  on  the  Uterus  and  Vagina. — Inasmuch  as  the  head 
completely  fills  the  brim  in  generally  contracted  pelvis,  it  tends 
to  press  uniformly  all  round  upon  the  lower  uterine  segment 
and  other  pelvic  structures.  In  consequence  of  this,  there  is  first 
a  tendency  to  the  occurrence  of  oedema  of  all  the  tissues  below 
the  girdle  of  contact,  and  secondly  an  increased  risk  of  the  cervix 
being  torn  off  as  a  ring.  Laceration  of  the  uterus  other  than  in 
this  way  is  rare,  as  extreme  degrees  of  contraction  seldom  occur, 
and  as  the  condition  of  affairs  is  more  readily  recognised  early  in 
labour  than  it  is  in  flattened  pelvis. 

Diagnosis. — The  diagnosis  of  generally  contracted  pelvis  is 
made  by  finding  on  measurement  that  all  the  diameters  of  the 
brim  are  diminished  in  length,  but  that  they  still  preserve  their 
normal  relation  to  one  another. 

Treatment. — In  contraction  of  the  first  degree,  delivery  must 
be  left  for  as  long  as  possible  to  the  natural  efforts,  in  order  to 
allow  the  head  to  mould  through  the  brim,  as  this  method  of 
treatment  offers  the  best  prospect  of  success.  Prophylactic 
version  is  contra-indicated  in  generally  contracted  pelvis,  for  the 
reasons  already  mentioned.  Premature  rupture  of  the  mem- 
branes is  not  so  liable  to  occur  in  this  form  of  contraction  as  in 
flattened  pelvis,  and  so  the  first  stage  of  labour  will  probably 
proceed  normally.  The  patient  should  remain  in  bed,  to 
minimise  any  risk  of  rupture  of  the  membranes,  and  should  lie 
on  the  side  towards  which  the  posterior  fontanelle  is  turned,  in 
order  to  favour  the  descent  of  the  latter,  and  so  assist  the 
mechanism  peculiar  to  this  form  of  contraction.  If  the  head 
continues  to  descend,  no  further  interference  need  take  place. 
If,  on  the  other  hand,  the  head  becomes  impacted  and  ceases  to 
advance,  it  is  best  to  attempt  to  deliver  the  foetus  at  once,  and 
not  to  wait  until  oedema  of  the  vagina  occurs.  If  the  foetal  heart 
can  be  heard,  an  attempt  may  be  made  to  extract  the  foetus  with 
the  forceps,  and,  in  this  degree  of  contraction,  will  probably 
be  successful,  provided  that  deep  engagement  of  the  posterior 
fontanelle  has  occurred.  If  the  foetus  is  dead,  or  if  attempts  at 
extraction  with  the  forceps  fail,  it  will  be  necessary  to  perform 
craniotomy. 

In  the  second  degree  of  pelvic  contraction,  premature  labour 


THE  FLAT  PELVIS  745 

must  always  be  induced  if  the  case  is  seen  sufficiently  early  in 
pregnancy.  When  this  course  has  not  been  adopted,  a  choice 
must  be  made  between  symphysiotomy  and  Caesarean  section,  if 
the  foetus  is  to  be  saved.  Prophylactic  version  is  contra-indicated 
for  the  reasons  already  given.  If  the  circumstances  of  the  case 
forbid  the  performance  of  the  first-named  operations,  craniotomy 
must  be  performed,  unless  it  is  obvious  that  the  head  of  the 
foetus  is  very  small,  when  attempts  to  extract  it  by  means  of  the 
forceps  are  perhaps  permissible.  Attempts  to  drag  a  normally- 
sized  head  through  a  pelvis  of  this  size  would  lead  to  so 
much  laceration  of  the  maternal  soft  parts  that  they  are  quite 
unjustifiable. 

Flattened  Pelvis. 

A  flattened  pelvis  is  one  in  which  the  chief  contraction  occurs 
in  the  conjugate  diameter,  and  in  which  the  other  diameters 
either  remain  approximately  unaltered  in  length  or  exhibit  a 
slight  general  contraction. 

Varieties. — The  following  varieties  of  flattened  pelvis  are  met 
with  :  — 

(i)  Flat  pelvis. 

(a)  Non-rachitic. 

(b)  Rachitic. 

(2)  Generally  contracted  flat  pelvis. 

(a)  Non-rachitic. 

(b)  Rachitic. 

(3)  Pelvis  of  congenital  dislocation  of  the  hips. 

Frequency. — The  non-rachitic  and  rachitic  flat  pelves  are  the 
varieties  of  pelvic  deformity  most  commonly  met -with.  According 
to  Winckel's  statistics,  they  occur  in  95*53  per  cent,  of  all  cases 
of  pelvic  deformity.  The  rachitic  generally  contracted  flat  pelvis 
is  next  in  frequency,  and  is  said  to  be  the  only  variety  of  extreme 
pelvic  deformity  met  with  in  England  (Herman).  It  is,  how- 
ever, rare  in  comparison  with  flattened  pelvis,  and  according  to 
Winckel  only  constitutes  about  one  per  cent,  of  cases  of  pelvic 
deformity.  The  non-rachitic  generally  contracted  flat  pelvis  and 
the  pelvis  of  congenital  dislocation  of  the  hips  are,  on  the  other 
hand,  among  the  rarest  forms  of  deformity. 

The  Flat  Pelvis. — The  essential  feature  of  both  the  non- 
rachitic and  the  rachitic  varieties  of  flat  pelvis  is  a  diminution 
in  the  length  of  the  true  conjugate,  unaccompanied  by  any 
diminution  in  the  other  diameters.  Although  this  characteristic 
is  common  to  both  varieties,  the  exact  anatomical  features  differ 
in  each  variety,  and  consequently  must  be  described  separately. 

The  Non-rachitic  Flat  Pelvis. — The  flattened  non-rachitic  or 
simple   flat  pelvis  is,  except  in  minor  degrees,  only  rarely  met 


746 


THE  PATHOLOGY  OF  LABOUR 


with.  Its  causation  has  not  as  yet  been  definitely  determined, 
though  some  writers,  regarding  it  as  really  the  result  of  mild 
rickets,  consider  that  it  should  more  properly  be  classified  along 
with  the  rachitic  variety.  It  is  more  generally  believed,  however, 
to  be  produced  by  very  severe  work,  involving  much  standing 
and  the  carrying  of  heavy  weights  during  childhood,  when  the 
bones  are  in  a  plastic  condition.  Probably  this  is  a  predisposing 
factor  in  the  majority  of  cases,  but  since  no  deformity  of  the 
sacrum  exists,  it  would  seem  that  some  abnormal  laxity  or  weak- 
ness of  the  posterior  sacro-iliac  ligaments  must  also  be  present  to 
permit  of  simple  displacement  of  that  bone.     It  is  probable  that 


Fig.  307. — The  Flattened  Pelvis.     Rachitic  Flat  Pelvis. 
Typical  Minor  Degree. 


in  some  cases  such  a  relaxation  takes  place  at  the  period  of 
puberty,  as  a  result  of  anaemia  and  general  debility,  which  in 
their  severe  forms  lead  to  the  lateral  curvature  of  the  spine  so 
common  at  this  age. 

The  sacrum  is  normal  in  shape,  but,  without  any  rotation 
around  its  transverse  axis,  it  is  displaced  bodily  downwards  and 
forwards  into  the  pelvis,  and  thus  produces  an  antero-posterior 
contraction,  which  is  slightly  more  marked  at  the  inlet,  but 
is  also  present  throughout  the  whole  extent  of  the  pelvis.  In 
comparison  with  the  conjugate,  the  transverse  and  oblique 
diameters  are  relatively  lengthened.  Sometimes,  the  transverse 
diameter  is  actually  lengthened,  but  in  the  majority  of  cases  it 


THE  FLAT  PELVIS 


747 


is  slightly  shortened.  The  whole  pelvis,  indeed,  is  often  small, 
and  this  is  usually  regarded  as  evidence  that  there  is  a  general 
slight  arrest  of  development  in  the  pelvic  bones,  since,  if  this 
was  not  the  case,  the  flattening  would  necessarily  produce  a 
compensatory  increase  in  the  transverse  diameter.  On  this 
account,  the  deformity  is  often  supposed  to  be  the  result  of  con- 
genital causes.  If,  however,  we  suppose  the  deformity  to  be 
produced  at  puberty  in  the  manner  described,  there  is  no  need  to 
assume  such  a  hypothesis,  since,  owing  to  the  elongation  of  the 
posterior  arm  of  the  iliac  lever,  the  ossa  innominata  at  that  period 
are  sufficiently  firm  to  resist  the  increased  outward  force  exerted 
upon  them  in  the  region  of  the  acetabula.  Moreover,  the  general 
arrest  of  development  brought  about  by  anaemia  is  sufficient  to 
account  for  the  smallness  of  the  pelvis.     This  view  is  borne  out 


Fig.  308.— Rachitic  Flat  Pelvis.     Typical  Minor  Degree. 

A,  Outline  of  brim  ;  B,  sagittal  section.     (Outline  of  normal  pelvis  in 

black,  of  contracted  pelvis  in  red.) 

by  the  fact  that,  in  many  cases,  when  the  transverse  diameter  is 
diminished  in  length,  the  os  innominatum  is  not  unduly  curved. 

As  a  result  of  the  sacral  displacement,  the  posterior  superior 
iliac  spines  approach  more  closely  than  normal  to  the  middle 
line  behind  the  sacrum,  and  thus  constitute  an  important  aid  to 
the  diagnosis  of  the  condition. 

The  Rachitic  Flat  Pelvis. — The  changes  found  in  the  rachitic 
variety  of  flattened  pelvis  are,  for  the  most  part,  the  direct  results 
of  the  pressure  of  the  body- weight  acting  downwards  through  the 
sacrum,  and  of  the  counter-pressure*  acting  upwards  and  inwards 
through  the  heads  of  the  femora  upon  bones  which  have  become 
softened  and  atrophic  from  disease.     The  amount  of  flattening 

*  The  counter-pressure  alone  does  not  act  inwards,  but  the  combined  forces 
of  the  reaction  to  body-weight  and  of  muscular  action  act  upon  the  aceta- 
bula in  the  direction  stated. 


748 


THE  PATHOLOGY  OF  LABOUR 


and  general  deformity  produced  depends,  first,  upon  the  duration 
and  severity  of  the  rickets,  and,  secondly,  upon  the  forces  acting 
upon  the  pelvis. 

In  infants,  the  body-weight  is  the  most  important  of  these 
forces,  and  is  responsible  for  the  greater  part  of  the  deformity 
since  the  disease  usually  sets  in  before  walking  or  standing  is 
attempted,  and  having  once  set  in,  prevents  both  walking  and 
standing.  For  this  reason,  there  is  but  little  counter-pressure 
against  the  acetabula,  and  the  effects  of  muscular  action,  though 
manifest,  are  diminished.  The  changes  which  rickets  produces 
in  the  skeleton  are  twofold.  First,  it  retards,  and  even  for  a 
time    completely   arrests,  bony    development,  and   therefore   the 


Fig.'  309. — The  Flattened  Pelvis.  Rachitic  Flat  Pelvis.  An  Ex- 
treme Degree  associated  with  Dislocation  of  Left  Sacro-iliac 
Joint  and  Consequent  Slight  Obliquity. 

pelvis  is  found  to  retain  throughout  life  several  of  its  infantile 
characteristics.  Secondly,  distinct  pathological  changes  occur. 
The  bones  become  softened  owing  to  a  deficiency  in  the  deposi- 
tion of  calcium  salts,  and  the  amount  of  cartilage  in  the  neigh- 
bourhood of  joints  and  between  the  growing  ends  of  the  bones 
becomes  increased  in  amount.  This  latter  change  is  especially 
marked  in  the  acetabular  cartilage  which  unites  the  ilium,  ischium 
and  os  pubis,  and  the  innominate  bones  are  in  consequence  liable 
to  yield  at  this  weakened  part.  When  recovery  once  sets  in  the 
bones  rapidly  ossify,  and,  in  the  adult,  their  structure  is  some- 
times normal.  As  a  rule,  however,  they  are  more  slender  and 
thinner  than  normal,  or  else  unusually  dense  and  hard.  In  some 
pelves,  localised  deposits  of  bone  beneath  the  periosteum  are  laid 


THE  FLAT  PELVIS  749 

down  to  act  as  buttresses  for  the  support  of  distorted  parts,  and 
occasionally  the  whole  of  both  the  external  and  the  internal  aspect 
of  the  bones  are  covered  with  small  spine-like  protuberances. 

The  sacrum  is  sunk  deeply  between  the  iliac  bones,  being 
displaced  forwards  and  downwards  by  the  body-weight,  and  is 
at  the  same  time  rotated  forwards  on  its  transverse  axis,  so  that 
the  sacral  promontory  projects  disproportionately  at  the  pelvic 
brim,  causing  great  shortening  of  the  conjugata  vera,  and  often 
giving  the  inlet  a  reniform  outline.  Its  lateral  halves,  moreover, 
are  often  somewhat  unequal.  The  upper  two-thirds  of  the  bone 
are  almost  straight,  and  are  directed  nearly  horizontally  back- 
wards, but  the  lower  third  is  bent  sharply  forwards,  and  makes 
an  obtuse  angle  with  the  upper  portion,  so  that  the  vertical 
curvature  as  a  whole  is  increased.     The  general  rotation  of  the 


A  B 

Fig.  310. — The  Rachitic  Flat  Pelvis.     Extreme  Degree. 

A,  Outline  of  brim  ;  B,  sagittal  section.     (Outline  of  normal  pelvis  in  black, 
of  contracted  pelvis  in  red.) 

sacrum  prevents  the  lower  part  from  causing  an  obstruction 
at  the  outlet.  The  normal  transverse  curvature  is  absent,  and 
the  front  of  the  bone  is  flat,  or  even  slightly  convex,  from  side 
to  side,  due  to  the  bodies  of  the  sacral  vertebrae  being  displaced 
further  forwards  than  the  lateral  portions,  which  are  anchored  in 
position  by  the  ligaments  binding  them  to  the  ilium.  Frequently, 
also,  that  portion  of  the  ilium,  which  lies  on  each  side  of  the 
sacrum  and  bounds  the  postero-lateral  portion  of  the  true  pelvis, 
is  pushed  forwards  by  the  pressure  of  the  lateral  masses  of  the 
sacrum,  and  forms  a  rounded  angle  with  the  anterior  part  of  the 
os  innominatum  above  the  great  sciatic  notch.  In  these  cases, 
the  reniform  shape  of  the  inlet  already  referred  to  is  very  evident. 
The  lessening  of  the  inward  pressure  exerted  by  the  heads  of 
the  femora  upon  the  ossa  innominata,  together  with  the  excessive 


750  THE  PATHOLOGY  OF  LABOUR 

formation  of  cartilage  in  these  bones,  enables  the  body-weight  to 
manifest  itself  more  effectively,  and  consequently  the  bones 
present  an  excessive  degree  of  outward  curvature.  The  trans- 
verse diameter  of  the  brim  is  therefore  increased  relatively  to 
the  conjugate,  but,  in  many  pelves,  though  relatively  increased, 
it  is  actually  diminished,  as  a  result  of  the  general  mal-develop- 
ment  produced  by  the  rickets. 

Other  results  of  the  excessive  bending  of  the  innominate 
bones  are  an  unusual  prominence  of  the  anterior  parts  of  the 
ilio-pectineal  lines,  and  a  flattening  of  the  bodies  of  the  pubic 
bones  so  that  they  become  almost  straight  from  side  to  side.  The 
pubic  arch  also  is  greatly  widened.  The  conjugate  diameter, 
which  has  been  seen  to  be  much  shortened  at  the  inlet,  undergoes 
an  immediate  and  considerable  increase  in  length  below  the  brim, 
on  account  of  the  curvature  and  position  of  the  sacrum.  At  the 
outlet,  it  again  undergoes  some  diminution,  but  not  to  any  marked 
extent,  and  this  diameter  may  be  even  longer  than  in  the  normal 
pelvis. 

The  tubera  ischii  are  widely  separated  and  somewhat  everted, 
partly  due  to  the  curvature  of  the  innominate  bones,  and  partly 
to  the  pull  of  the  adductor  muscles  of  the  thigh.  The  transverse 
diameter  is  therefore  widened  at  the  outlet.  The  general  result 
of  these  changes  is  to  produce  a  pelvis  flattened  at  the  brim,  and 
increasing  in  capacity  from  above  downwards  in  both  the  con- 
jugate and  transverse  directions. 

In  the  false  pelvis,  the  iliac  fossae  are  flatter  and  more  vertical 
than  normal,  and  look  almost  directly  forwards.  The  curvature 
of  the  iliac  crest  is  diminished,  probably  owing  to  a  persistence 
of  the  infantile  type,  and  the  anterior  superior  iliac  spines  are 
directed  rather  outwards  than  forwards,  so  that  the  distance 
between  them  is  as  great,  or  even  greater,  than  between  any 
other  corresponding  points  on  the  crests.  In  consequence  of  the 
position  of  the  sacrum,  the  posterior  iliac  spines  approach  one 
another  closely. 

Symptoms. — The  special  symptoms  of  flat  pelvis  differ  to  some 
extent  from  those  of  generally  contracted  pelvis.  They  will  be 
discussed  under  the  same  headings  as  in  the  former  case. 

(i)  Effect  on  the  Relation  of  the  Head  to  the  Brim. — In  the 
early  months  of  pregnancy  there  is  an  increased  liability  to  the 
occurrence  of  incarceration  of  a  retroverted  uterus,  in  consequence 
of  the  manner  in  which  the  sacral  promontory  overhangs  the 
pelvic  cavity.  As  the  degree  of  narrowing  of  the  conjugate  is 
usually  considerable,  the  presenting  head  is  unable  to  adapt  itself 
to  the  pelvic  brim  as  in  normal  cases,  and  consequently  during 
pregnancy  the  uterus  is  pushed  upwards  out  of  the  pelvic  cavity. 
As  a  result  of  this,  pendulous  abdomen  and  malpresentations  are 
common  during  the  latter  part  of  pregnancy.  During  labour, 
for  the  same  reason,  the  head  is  unable  to  fill  the  lower  uterine 
segment,  and  premature  rupture  of  the  membranes,  sudden  and 


THE  FLAT  PELVIS  751 

complete  escape  of  the  liquor  amnii,  and  consequent  slow  dilata- 
tion of  the  uterine  orifice,  are  the  rule. 

(2)  Effect  on  the  Foetus. — The  caput  succedaneum  is  of  large 
size,  though  it  does  not  reach  the  dimensions  that  it  usually  reaches 
in  cases  of  generally  contracted  pelvis.  At  first,  it  forms  in 
the  region  of  the  anterior  fontanelle,  and  then  travels  backwards 
over  the  surface  of  the  anterior  or  posterior  parietal  bone,  accord- 
ing as  one  or  other  presents.  The  moulding  of  the  head  is  not 
as  great  as  in  generally  contracted  pelvis,  although  the  actual 
pressure  on  the  head  is  perhaps  greater.  This  can  be  readily 
understood,  if  we  remember  that  in  generally  contracted  pelvis 
pressure  is  exerted  on  the  head  uniformly  all  round  by  the  brim, 
while,  in  flattened  pelvis,  the  pressure  is  mainly  exerted  on  two 
points  of  the  head  by  the  promontory  and  the  symphysis.  In 
consequence,  in  the  former  case  there  is  a  tendency  for  an 
exaggerated  degree  of  the  normal  process  of  moulding  to  occur, 
while,  in  the  latter  case,  the  tendency  is  rather  to  the  occurrence 
of  dinting  of  the  bone  which  is  in  relation  to  the  promontory. 
In  this  way,  the  posterior  parietal  bone  is  flattened,  and,  in  the 
greater  degrees  of  contraction,  a  large  spoon-shaped  or  funnel- 
shaped  depression  may  be  found  on  it,  or  even  fracture  of  the 
bone  may  occur.  In  the  lesser  degrees  of  contraction,  a  gutter- 
shaped  groove  is  found  running  parallel  with  the  sagittal  suture. 
In  the  case  of  an  after-coming  head,  this  groove  runs  from  the 
anterior  inferior  angle  of  the  parietal  bone  upwards  and  back- 
wards towards  the  parietal  eminence. 

(3)  Effect  on  the  Mechanism  of  Expulsion. — -The  alterations 
which  are  met  with  in  the  normal  mechanism  of  a  vertex 
presentation  in  flattened  pelvis  are  due  to  two  things  : — First,  to 
the  obstruction  offered  to  the  descent  of  the  bi-parietal  diameter 
of  the  head  ;  and,  secondly,  to  the  resistance  of  the  promontory. 
The  obstruction  offered  to  the  descent  of  the  bi-parietal  diameter 
results  in  an  alteration  in  the  presentation  and  in  the  relation  of 
the  head  to  the  brim.  In  consequence  of  the  narrowed  conjugate, 
the  head  is  unable  to  engage  in  the  ordinary  manner  with  its 
antero-posterior  diameters  corresponding  to  one  or  other  oblique 
diameter  of  the  brim,  and  is  forced  instead  into  a  transverse 
position,  where  it  lies  with  a  diameter  slightly  anterior  to  the 
sub-occipito-bregmatic  diameter,  corresponding  to  the  transverse 
diameter  of  the  brim.  In  this  position,  the  bi-parietal  diameter  is 
slightly  to  one  side  of  the  conjugate,  but  is  still  prevented  from 
descending  by  the  pelvic  contraction.  The  anterior  part  of 
the  head  is,  however,  free  to  descend,  and,  as  it  is  driven  down- 
wards by  the  contraction,  the  head  becomes  slightly  extended, 
with  the  result  that  a  diameter  which  approximately  corresponds 
to  the  occipito-frontal  diameter  comes  to  lie  in  the  transverse 
diameter  of  the  pelvis,  and  that  the  anterior  fontanelle  constitutes 
the  presenting  point.  At  the  same  time,  the  entire  head  glides 
laterally  towards    the    side  of  the   pelvis  to  which  the  occiput 


752  THE  PATHOLOGY  OF  LABOUR 

points,  and  thus  brings  the  bi-parietal  diameter  into  the  lateral 
sweep  of  the  brim,  where  there  is  more  room  for  it,  and  also 
brings  the  smaller  bi-temporal  diameter  into  the  conjugate.  The 
effect  of  these  changes  is  that  the  head  presents  at  the  brim 
with  the  fronto-occipital  diameter  corresponding  to  the  transverse 
diameter  of  the  pelvis  and  the  bi-temporal  diameter  to  the  con- 
jugate diameter,  and  the  anterior  fontanelle  lowest.  At  a  similar 
stage  in  a  normal  pelvis,  a  diameter  slightly  anterior  to  the  sub- 
occipito-bregmatic  diameter  corresponds  to  one  oblique  diameter 
of  the  pelvis  and  the  bi  parietal  diameter  to  the  opposite  oblique, 
and  the  vertex  lies  lowest.  The  resistance  of  the  promontory 
brings  about  a  further  alteration  in  the  relation  of  the  head  to 
the  brim.  On  account  of  the  manner  in  which  the  pro- 
montory projects  into  the  brim,  the  resistance  offered  to  the 
descent  of  the  part  of  the  head  which  lies  in  contact  with  it, 
i.e.,  the  posterior  parietal  bone,  is  greater  than  the  resistance 
offered  to  the  part  of  the  head  in  contact  with  the  symphysis,  i.e., 
the  anterior  parietal  bone.  In  consequence,  the  latter  descends 
more  rapidly,  the  head  rotates  round  its  antero-posterior  diameter, 
the  sagittal  suture  approaches  the  promontory,  and  the  anterior 
parietal  bone  lies  lowest.  This  position  of  the  head  is  known 
as  posterior  asynclitism,  presentation  of  the  anterior  parietal 
bone,  or  Naegele's  obliquity.  In  cases  of  great  contraction, 
the  sagittal  suture  may  move  round  almost  into  contact  with  the 
promontory,  and  the  ear  replace  the  anterior  fontanelle  as  the 
presenting  point — a  so-called  ear  presentation.  In  practice,  we 
recognise  that  the  extent  to  which  Naegele's  obliquity  occurs 
is  an  indication  of  the  degree  of  contraction  present,  and  that,  if 
the  sagittal  suture  comes  within  half  an  inch  of  the  promontory, 
it  is  impossible  for  the  head  to  be  born  (Litzmann*).  If,  on  the 
other  hand,  the  degree  of  contraction  is  not  too  great,  the  anterior 
parietal  bone  becomes  fixed  behind  the  symphysis,  and  the  head 
rotating  round  it  as  a  fixed  point,  the  posterior  parietal  bone 
is  squeezed  past  the  promontory,  by  which  it  is  dinted  or  grooved 
to  a  varying  extent.  At  the  same  time,  the  occiput  passes  through 
the  brim,  and  once  this  has  occurred  the  remaining  mechanism 
of  the  case  is  similar  to  that  in  a  normal  pelvis,  as  the  diameters 
of  the  cavity  and  outlet  are  usually  unaffected  in  flattened  pelvis. 

Anterior  asynclitism  of  the  head,  or  presentation  of  the 
posterior  parietal  bone,  or  Litzmann's  obliquity,  as  it  is  variously 
termed,  may  occur  in  a  few  cases,  instead  of  posterior  asynclitism. 
Such  a  condition  is  rare,  and  when  it  does  occur  will  usually 
prevent  the  passage  of  the  head.  The  mechanism,  which  is  said 
to  occur  in  the  few  cases  in  which  delivery  takes  place,  was 
described  when  discussing  anterior  asynclitism  of  the  head. 

In  the  case  of  the  after-coming  head,  a  mechanism  very  similar 
to  that  just  described  must  be  followed.  It  is  important  to 
remember  this,  in  order  that  when  delivering  the  head  we  may 
*  '  Die  Geburt  bei  engen  Becken,'  Leipzig,  1884. 


THE  FLAT  PELVIS  753 

make  the  latter  follow  such  a  mechanism.  The  after-coming  head 
must  pass  through  the  brim  in  a  transverse  position,  the  occiput 
as  far  to  one  or  other  side  as  it  will  go,  and  flexion  at  first  not  too 
marked.  Efforts  at  jaw  traction  may  tend  to  cause  too  great 
a  degree  of  flexion,  and  it  is  perhaps  for  that  reason  that  Martin's 
method,  in  which  delivery  is  effected  by  pressure  through  the 
abdominal  walls,  is  found  to  be  superior  in  these  cases  to 
Smellie's  method.  In  Martin's  method,  the  degree  of  flexion  can 
be  regulated,  while  in  Smellie's  method  flexion  is  of  necessity  as 
complete  as  the  resistance  to  the  descent  of  the  head  will  allow. 

(4)  Effect  on  the  Uterus  and  Vagina. — In  a  flattened  pelvis, 
the  head  does  not  fill  the  brim  in  the  same  complete  manner  as 
is  the  case  in  the  generally  contracted  pelvis,  but  rather  is  in 
contact  with  it  at  two  points  only— the  sacral  promontory  and 
the  back  of  the  symphysis.  In  consequence,  oedema  of  the  vagina 
and  vulva  is  not  as  commonly  met  with  as  in  generally  con- 
tracted pelvis.  On  the  other  hand,  rupture  of  the  uterus,  either 
in  the  thinned  lower  uterine  segment  or  by  rubbing  through  of 
the  portion  nipped  between  the  head  and  the  two  points  of 
contact  with  the  pelvis,  is  more  common. 

Diagnosis. — The  diagnosis  of  flattened  pelvis  is  made  by  finding 
that  the  conjugate  diameter  of  the  brim  is  diminished,  while  the 
other  diameters  are  normal  in  length. 

Treatment.  —  In  contraction  of  the  first  degree,  we  have  a  choice 
between  allowing  the  head  to  mould  through  the  brim,  and  per- 
forming prophylactic  version.  As  the  degree  of  contraction  is 
slight,  the  former  method  offers  the  best  prospect  of  success,  and 
should  be  adopted  unless  there  is  some  reason  to  suppose  that  the 
head  is  above  the  normal  size,  in  which  case  prophylactic  version 
may  be  preferable.  If  the  former  course  is  adopted,  the  moulding 
of  the  head  through  the  brim  must  be  left  to  the  natural  efforts  so 
long  as  it  is  possible  to  do  so  consistently  with  the  safety  of  the 
mother,  or  until  the  foetus  dies.  If  danger-signals  on  the  part  of 
the  mother  appear,  an  attempt  may  be  made  to  extract  the  foetus 
with  the  forceps  ;  and,  if  the  foetus  dies  during  labour,  perforation 
may  be  performed  in  order  to  save  the  mother  from  unneces- 
sary suffering.  So  long  as  the  head  remains  above  the  brim,  the 
forceps  is  contra-indicated,  as  it  interferes  with  the  mechanism 
peculiar  to  flattened  pelvis,  and,  moreover,  tends  to  increase  the 
lateral  and  antero-posterior  diameters  of  the  head,  as  has  been 
shown.  Once  the  head  has  passed  the  brim,  the  forceps  may  be 
applied,  if  it  is  necessary  to  do  so. 

In  the  second  degree  of  pelvic  contraction,  the  induction  of 
premature  labour  is  the  best  line  of  treatment.  If  the  patient  is 
not  seen  sufficiently  early  in  pregnancy  for  this  to  be  done, 
prophylactic  version  offers  the  best  prospect  of  saving  the  foetus, 
unless  we  perform  symphysiotomy  or  Caesarean  section.  In  this 
degree,  the  probability  of  the  head  moulding  through  the  brim  is 
too  unlikely  to  render  it  a  suitable  treatment  to  adopt.     Prophy- 

48 


754 


THE  PATHOLOGY  OF  LABOUR 


lactic  version,  on  the  other  hand,  if  performed  by  a  skilful 
obstetrician,  offers  a  fair  prospect  of  success.  As  has  been 
already  mentioned,  Martin's  method  offers  the  best  means  of 
delivering  the  after-coming  head.  The  latter  must  be  brought 
through  the  brim  with  its  antero-posterior  diameter  correspond- 
ing to  the  transverse  diameter  of  the  brim,  with  the  occiput  as 
close  as  possible  to  the  side  of  the  brim  towards  which  it  is 
turned,  and  without  an  undue  degree  of  flexion.  At  the  same 
time,  care  must  be  taken  not  to  allow  the  chin  to  catch  above 
the  side  of  the  brim,  as  if  that  occurred  the  prospect  of  delivering 
the  foetus  alive  would  be  very  small.  As  soon  as  the  brim  is 
passed,  the  face  is  rotated  posteriorly  and  the  degree  of  flexion 
may  be  increased.     The  remainder  of  the  delivery  of  the  head 


Fig.  311. — The  Flattened  Pelvis.     Rachitic  Generally 
Contracted  Flat  Pelvis. 


is  similar  to  that  in  a  normal  pelvis.  If  the  patient  is  not  seen 
until  too  late  in  labour  to  perform  version,  there  is  as  a  rule 
nothing  to  be  done  save  to  perforate,  or,  if  the  circumstances 
are  favourable,  to  perform  symphysiotomy.  Attempts  to  extract 
with  the  forceps  in  the  case  of  a  head  of  normal  size  are 
inadmissible,  on  account  of  the  danger  to  the  mother. 

The  Generally  Contracted  Flat  Pelvis. — The  essential 
feature  of  the  generally  contracted  flat  pelvis  is  contraction  of  all 
the  diameters  of  the  brim,  especially  marked  in  the  true  conju- 
gate, which  is  diminished  out  of  proportion  to  the  other  diameters. 
This  form  of  contraction  includes  two  varieties,  the  simple  or 
non-rachitic  generally  contracted  flat  pelvis,  and  the  rachitic 
generally  contracted  flat  pelvis. 


THE  GENERALLY  CONTRACTED  FLAT  PELVIS  755 

The  Non-Rachitic  Generally  Contracted  Flat  Pelvis.  —  This 
variety  is  the  rarer  of  the  two.  It  resembles  a  justo-minor  pelvis 
in  which  the  sacrum  has  become  depressed  into  the  pelvic  cavity, 
with  consequent  diminution  of  the  conjugate  diameter  out  of  pro- 
portion to  the  diminution  of  the  other  diameters.  It  is  probably 
the  result  of  causes  similar  to  those  which  produce  a  justo-minor 
pelvis,  and  can  be  distinguished  from  the  rachitic  variety  by  the 
absence  of  deformity  of  the  sacrum.  Occasionally  flattening, 
with  general  contraction,  results  from  faulty  development  of  the 
os  innominatum,  without  sacral  displacement.  The  anterior 
portion  of  this  bone  remains  shorter  than  normal,  possibly  due  to 
premature  osseous  union  with  the  posterior  part,  and  conse- 
quently leads    to   antero-posterior   contraction.     The   transverse 


A  B 

Fig.  312. — The  Rachitic  Generally  Contracted  Flat  Pelvis. 

A,  Outline  of  brim  ;   B,  sagittal  section.      (Outline  of  normal  pelvis  in  black, 
of  contracted  pelvis  in  red.) 

diameter  also  is  short,  because  the  early  ossification  prevents  the 
development  of  the  normal  curves  of  the  bones. 

The  Rachitic  Generally  Contracted  Flat  Pelvis. — This  variety  is 
comparatively  common,  but  does  not  require  any  lengthy  descrip- 
tion, because  it  is  almost  identical  in  appearance  with  the  flat 
rachitic  pelvis,  except  that  there  is  more  general  contraction.  It 
is  the  result  of  rachitis  of  a  more  severe  type  than  that  which 
leads  to  the  flat  rachitic  pelvis,  and  which  is  responsible  not  only 
for  the  flattening,  but  also  for  the  pronounced  arrest  of  develop- 
ment of  the  bones  which  leads  to  general  contraction.  The 
sacrum  is  deformed  and  displaced,  and  the  bones  are  charac- 
teristically rickety.  It  is,  as  would  be  expected,  most  commonly 
found  in  small  women. 

Symptoms. — The  symptoms  of  generally  contracted  flat  pelvis 
are    perhaps    more    marked    than    are    those    of    either   of    the 

48—2 


756 


THE  PATHOLOGY  OF  LABOUR 


forms  with  which  we  have  so  far  dealt,  and  are — as  is  natural — 
composed  of  those  peculiar  to  both  these  forms. 

(i)  Effect  on  the  Relation  of  the  Head  to  the  Brim. — In  this 
form  of  pelvis,  the  brim  is  somewhat  triangular  in  shape,  and  the 
degree  of  contraction  is  often  considerable.  The  head  is  found 
completely  above  the  brim  at  the  commencement  of  labour,  and, 
consequently,  pendulous  abdomen  is  the  rule  and  malpresenta- 
tions  are  very  common.  Even  when  the  head  enters  the  brim, 
it  does  not  fill  the  latter,  nor  can  it  descend  into  and  fill  the 
lower  uterine  segment  ;  consequently,  premature  rupture  of  the 
membranes  and  complete  escape  of  the  liquor  amnii  are  the 
rule. 

(2)  Effect  on  the  Foetus. — As  the  head  usually  enters  the  brim 
in  a  flexed  position,  the  caput  succedaneum  forms  in  the  region  of 


Fig.  313. — Pelvis  of  Congenital  Dislocation  of  the  Hips. 

the  posterior  fontanelle,  and  attains  a  large  size.  Considerable 
moulding  of  the  head  occurs,  and  marked  dinting  and  grooving  of 
the  posterior  parietal  bone  are  even  more  common  than  in  flat 
pelvis. 

(3)  Effect  on  the  Mechanism  of  Expulsion. — The  effects  on  the 
mechanism  of  expulsion  of  the  general  contraction  and  of  the 
flattening  of  the  brim  are  very  obvious.  The  head  enters  the 
brim  in  a  degree  of  flexion  proportionate  to  the  degree  of  general 
contraction,  and  usually  with  the  sub-occipito-bregmatic  diameter 
corresponding  to  the  transverse  diameter  of  the  pelvis.  Naegele's 
obliquity  or  posterior  asynclitism  usually  occurs,  but  in  some  cases 
— one-fifth  (Winckel) — anterior  asynclitism  may  be  met  with. 
Internal  rotation  occurs  later  than  usual,  and  the  head  may  even 
emerge  in  an  oblique  or  transverse  position.  This,  and  the  fact 
that  delivery  is  usually  rapid  once  the  head  has  passed  the  brim, 
.are  due  to  the  increase  which   occurs  in   the  diameters  of  the 


THE  PELVIS  OF  CONGENITAL  DISLOCATION  OF  THE  HIPS     757 

pelvic  cavity  in  this  variety  of  contraction  on  account  of  the 
divergence  of  the  pelvic  walls. 

(4)  Effect  on  the  Uterus  and  Vagina. — Laceration  of  the  cervix, 
rupture  of  the  lower  uterine  segment,  or  rubbing  through  of  a 
nipped  portion  of  the  uterine  wall,  are  especially  common  in  this 
form  of  contraction. 

Treatment. — The  treatment  of  generally  contracted  flat  pelvis  is 
in  the  main  similar  to  that  of  generally  contracted  pelvis.  Inas- 
much as  the  posterior  fontanelle  presents  at  the  brim,  the  applica- 
tion of  the  forceps  in  contraction  of  the  first  degree,  when  the 
head  fails  to  mould  through  the  brim,  may  have  a  better  chance 
of  success  than  it  has  in  flat  pelvis,  while,  on  account  of  the 
general  contraction,  extraction  of  the  after-coming  head  after  pro- 
phylactic version  is  usually  difficult. 


A  B 

Fig.  314. — Pelvis  of  Congenital  Dislocation  of  the  Hips. 

A,  Outline  of  brim ;  B,  sagittal  section.  In  this  specimen  there  is  no 
noticeable  flattening.  (Outline  of  normal  pelvis  in  black,  of  contracted 
pelvis  in  red.) 

The  Pelvis  of  Congenital  Dislocation  of  the  Hips. — The 
form  of  pelvis  met  with  in  the  condition  which  is  usually 
termed  double  congenital  dislocation  of  the  hips  is  one  which, 
from  a  developmental  point  of  view,  is  of  extreme  interest, 
although  it  gives  rise  to  only  slight  difficulty  during  labour.  It 
is  a  rare  form  of  pelvic  contraction. 

In  cases  of  congenital  dislocation  of  the  hips,  the  heads  of  the 
femora  most  commonly  articulate  with  the  dorsum  ilii  above  and 
behind  the  region  of  the  acetabula,  and  at  the  same  time  are 
placed  farther  apart  than  is  normal.  The  resultant  changes  in 
the  pelvis  are  caused,  firstly,  by  the  transmission  downwards  of 
the  body-weight  along  a  more  posterior  plane  than  normal,  and, 
secondly,  by  the  altered  action  of  the  various  groups  of  muscles 


758  THE  PATHOLOGY  OF  LABOUR 

attached  to  the  pelvis  and  femora,  owing  to  the  change  in  the 
level  of  their  attachment  and  of  their  direction. 

Owing  to  the  position  of  the  femora,  the  anterior  support  of 
the  pelvis  is  removed,  and  is  replaced  by  a  force  which  tends  to 
drive  the  posterior  half-ring  of  the  pelvis  upwards,  and  to  increase 
the  pelvic  obliquity.  At  the  same  time,  the  pull  of  the  ilio-femoral 
ligaments  and  of  the  ilio  psoas  muscles  tends  to  displace  the 
anterior  part  of  the  pelvis  backwards,  and  thus  still  further  to 
increase  the  obliquity.  The  extent  of  the  action  of  the  ilio-psoas 
in  this  direction  is  shown  by  the  depth  of  the  groove  which  the 
muscle  hollows  out  on  the  ilium  behind  Poupart's  ligament, 
where  it  plays  against  the  bone. 

The  increase  of  pelvic  inclination  causes  a  greater  proportion 
of  the  body-weight  than  normal  to  exert  its  action  along  the  plane 
of  the  inlet,  and  this,  combined  with  the  want  of  anterior  support, 
results  sometimes  in  a  depression  of  the  promontory  of  the  sacrum, 
and  consequently  causes  a  moderate  degree  of  flattening  at  the 
brim.  The  vertical  curvature  of  the  sacrum  is  somewhat  in- 
creased, and  the  coccyx  projects  downwards  into  the  pelvis,  but 
since  it  is  at  the  same  time  rotated  upwards,  the  conjugate 
diameter  of  the  outlet  is  not  diminished  in  length,  and  even  may 
be  increased. 

The  absence  of  inward  pressure  against  the  acetabula  causes 
the  normal  curvature  of  the  os  innominatum  to  become  ac- 
centuated, and  thus  leads  to  slight  increase  of  the  transverse 
diameter  at  the  inlet.  The  transverse  diameter  of  the  outlet  is 
also  widened,  but  in  a  more  marked  degree,  the  tubera  ischii  being 
pulled  forwards  and  outwards  by  the  muscles  attached  to  them, 
while  at  the  same  time  the  sub-pubic  angle  is  enlarged.  The 
upward  thrust  of  the  femora  posteriorly,  in  addition  to  producing 
increased  pelvic  obliquity,  causes  the  venter  ilii  on  each  side  to 
assume  an  almost  vertical  position,  and  frequently  the  crest  may 
be  seen  projecting  outwards  under  the  skin.  The  bones  of  the 
posterior  part  of  the  pelvis  are  dense  and  large,  in  consequence  of 
the  increased  pressure  which  is  thrown  upon  them.  On  the  other 
hand,  the  anterior  part  of  the  pelvis,  which  has  little  weight  to 
sustain,  is  thin  and  slender. 

Patients,  who  are  the  subjects  of  this  deformity,  can  be  readily 
recognised  by  the  marked  lordosis  of  the  lumbar  and  lower  dorsal 
vertebrae — a  lordosis  which  is  developed  compensatory  to  the 
great  pelvic  obliquity,  and  by  the  fact  that  the  abdomen  lies  on 
a  plane  anterior  to  the  anterior  aspect  of  the  thighs.  If  con- 
genital dislocation  exists  on  one  side  only,  an  oblique  deformity 
of  the  pelvis  is  produced. 

Diagnosis. — The  diagnosis  can  frequently  be  made  from  the 
waddling  manner  in  which  the  patient  walks,  resembling  the 
mode  of  progression  of  a  duck.  On  examination  of  the  pelvis, 
when  the  patient  is  lying  down,  the  great  trochanter  of  the  femur 
will  be  found  above  Nelaton's  line,  i.e.,  the  line  joining  the  anterior 


THE  PELVIS  OF  CONGENITAL  DISLOCATION  OF  THE  HIPS      759 

superior  spine  and  the  tuberosity  of  the  ischium  on  the  same 
side.  Under  ordinary  circumstances,  this  line  touches  the  top  of 
the  trochanter. 

Treatment. — The  degree  of  contraction  met  with  in  this  pelvis  is 
not  as  a  rule  sufficiently  great  to  interfere  with  the  normal  pro- 
gress of  labour.  If,  however,  the  contraction  is  greater  than 
usual,  the  case  is  treated  in  a  similar  manner  to  a  flat  pelvis. 


CHAPTER  IV 
THE  RARE  FORMS  OF  CONTRACTED  PELVIS 

Obliquely  Distorted  Pelvis — The  Kypho-scoliotic  Pelvis — The  Coxalgic  Pelvis 
— The  Synostotic  Pelvis.  The  Transversely  Contracted  Pelvis — The  Bi- 
lateral Synostotic  Pelvis — The  Kyphotic  Pelvis.  The  Funnel-shaped 
Pelvis.  The  Irregularly  Compressed  Pelvis — The  Osteo-malacic  Tri- 
radiate  Pelvis — The  Rachitic  Triradiate  Pelvis.  The  Spondylolisthetic 
Pelvis.  Pelvis  Deformed  by  Tumours,  Fractures,  and  Dislocations. 
Split  Pelvis.     Pelvis  Justo-major. 

In  the  previous  chapter,  we  have  referred  to  certain  of  the 
rare  varieties  of  contracted  pelvis — viz.,  the  generally  contracted 
rachitic  pelvis,  the  dwarf  pelvis,  the  generally  contracted  flat  non- 
rachitic pelvis,  and  the  pelvis  of  congenital  dislocation  of  the  hips, 
because  the  nature  of  the  deformity  in  these  cases  and  the  effect 
on  labour  are  almost  identical  with  the  nature  and  the  effects  of 
the  common  varieties  of  contraction.  In  the  following  chapter, 
we  shall  discuss  the  remaining  classes  of  contracted  pelvis,  all  of 
which  are  of  rare  occurrence. 

According  to  the  classification  we  have  adopted,  we  have  still 
to  deal  with  the  following  classes  : — 

III.  Obliquely  Distorted  Pelvis. 

(i)  By  spinal  curvature — kypho-scoliotic  pelvis. 

(2)  By  imperfect  or  abolished  use  of  one  limb — cox- 

algic pelvis. 

(3)  By  asymmetry  of  the  sacrum — unilateral  synos- 

totic pelvis,  Naegele's  pelvis. 

IV.  Transversely  Contracted  Pelvis. 

(1)  Bilateral  synostotic  pelvis,  Robert's  pelvis. 

(2)  The  kyphotic  pelvis. 

V.  Funnel-shaped  Pelvis. 

VI.  Compressed  or  Triradiate  Pelvis. 

(1)  The  osteo-malacic  pelvis. 

(2)  The  rachitic  pelvis. 

VII.  Spondylolisthetic  Pelvis. 

760 


OBLIQUELY  DISTORTED  PELVIS  761 

VIII.  Pelvis  Narrowed  by  Exostoses,  Fractures,  and 
Bony  Tumours. 

IX.   Split  Pelvis. 

Obliquely  Distorted  Pelvis. 

An  obliquely  distorted  pelvis  is  one  in  which  there  is  a  deviation 
of  a  part  of  or  the  whole  pelvis  towards  one  or  other  side,  in  such 
a  manner  that  a  marked  difference  exists  in  the  respective  lengths 
of  the  oblique  diameters. 

Varieties. — Three  varieties  of  oblique  distortion  are  met  with, 
each  of  which  is  produced  by  a  different  cause.     These  are  : — 

(1)  By  spinal  curvature — kypho-scoliotic  pelvis. 

(2)  By  imperfect  or  abolished  use  of  one  limb — coxalgic 

pelvis. 

(3)  By  asymmetry  of   the   sacrum — unilateral   synostotic 

pelvis,  Naegele's  pelvis. 

Frequency. — Oblique  distortion  of  the  pelvis  is  a  rare  deformity 
in  these  countries.  According  to  Winckel's  statistics,  it  occurs  in 
two  per  cent,  of  cases  of  pelvic  deformity.  The  kypho-scoliotic 
pelvis  is  the  commonest  of  the  three  varieties. 

Aetiology  and  Characteristics. — In  all  these  varieties  of  oblique 
contraction,  one  important  factor  in  producing  the  obliquity  is 
constant,  and  consists  in  the  unequal  transmission  of  the  body- 
weight  through  the  lower  limbs,  whereby  the  effect  of  pressure 
from  above  and  counter-pressure  from  below  manifests  itself 
during  the  period  of  growth  to  a  greater  extent  upon  one 
os  innominatum  than  upon  the  other,  and  thus,  by  leading  to 
unequal  curvature  of  the  two  bones,  gives  rise  to  oblique 
deformity.  Important  differences,  however,  exist  in  the  different 
varieties,  because  in  one — the  oblique  synostotic  pelvis  —  the 
primary  obliquity  is  due  to  abnormal  development  or  pathological 
change  in  the  pelvis  itself;  while  in  the  other  two  varieties, 
which,  indeed,  might  be  grouped  together,  the  obliquity  is 
entirely  secondary  to  the  effects  of  pressure  unequally  trans- 
mitted to  the  lower  limbs  owing  to  changes  which  have  occurred 
outside  the  pelvis.  In  all  varieties,  the  following  defects  can  be 
noted  : — 

(1)  One  oblique  diameter  is  shorter  than  the  other. 

(2)  The  conjugate  diameter  deviates  from  the  sagittal  plane. 

(3)  The  ala  of  the  sacrum  on  the  side  of  greater  pressure  is 
imperfectly  developed,  and  the  curvature  of  the  os  innominatum 
on  the  same  side  is  diminished,  while  the  curvature  of  the  other 
os  innominatum  is  increased. 

(4)  The  pelvic  cavity  is  divisible  into  a  narrow  part,  towards 
which  the  sacral  promontory  is  directed,  and  into  a  wide  part, 
bounded  in  front  by  the  symphysis  pubis. 


762 


THE  PATHOLOGY  OF  LABOUR 


The  Kypho-scoliotic  Pelvis. — This  is  the  commonest  variety 
of  obliquely  contracted  pelvis.  It  is  the  result  of  a  scoliosis  or 
lateral  curvature  of  the  vertebral  column ;  and,  since  rickets  in 
early  life  is  the  most  common  cause  of  this,  the  oblique  distor- 
tion is  often  associated  with  some  degree  of  flattening  and  other 
rachitic  changes.  The  convexity  of  the  lateral  curvature  is  most 
often  directed  to  the  right  side  in  the  dorsal  region,  and  is  com- 
pensated by  a  left-sided  lumbar  scoliosis,  which  causes  the  left 
lower  limb  and  the  left  side  of  the  pelvis  to  be  overweighted.  As 
a  result  of  this  the  promontory  of  the  sacrum  is  deviated  to 
the   same  side  as  the  convexity  of    the  lumbar  curve,  and  the 


Fig.  315. — Oblique  Distortion  of  the  Pelvis. 

Pelvis. 


The  Kypho-scoliotic 


lateral  mass  of  the  sacrum  on  the  same  side  is  smaller  than 
normal,  even  the  anterior  sacral  foramina  on  the  overweighted 
side  being  diminished  in  size.  The  articular  surface  also  is  dis- 
placed downwards  and  forwards  upon  the  ilium,  while,  as  a  rule, 
the  long  axis  of  the  sacrum  is  directed  towards  the  sound  side. 

The  disproportionate  muscular  development  of  the  over- 
weighted side  causes  the  inward  thrust  of  the  head  of  the  femur 
against  the  acetabulum  to  be  increased  in  force,  and,  by  hindering 
the  development  of  the  normal  curvature  of  the  os  innominatum, 
brings  about  a  still  further  approximation  of  the  acetabulum  to 
the  sacro-iliac  joint,  the  latter,  as  we  have  already  seen,  being 
itself  displaced  forwards  upon  the  ilium.     Characteristic  features 


THE  KYPHO-SCOLIOTIC  PELVIS  763 

therefore,  in  all  these  cases,  are  marked  shortening  of  the  space 
between  the  sacro-iliac  joint  and  the  acetabulum,  and  the 
smallness  of  the  great  sciatic  notch  on  the  side  of  the  lumbar 
scoliosis.  Indeed,  if  the  bones  have  been  rendered  pliable  by 
rickets,  the  pressure  of  the  femur  may  cause  a  marked  angular 
bend  of  the  os  innominatum  posteriorly  at  its  weakest  place, 
where  it  bounds  the  great  sciatic  notch  above,  and  thus  convert 
the  above-mentioned  interval  into  a  passage  so  narrow  as  to 
prevent  the  entrance  of  any  part  of  the  fcetus.  The  anterior 
part  of  the  os  innominatum  always  maintains  an  almost  straight 
course. 

Another  effect  of  the  increased  pressure  of  the  femur  is  that 
the  symphysis  pubis  is  driven  over  towards  the  opposite  side. 
This  displacement  is  aided  by  the  fact  that,  as  the  healthy  os 
innominatum  is  hollowed  out,  it  exerts  a  pull  upon  the  symphysis, 
and   this  pull  is  not    counterbalanced  in  the  ordinary  way  by 


Fig.  316. — The  Kypho-scoliotic  Pelvis. 

Outline  of  brim.     (Outline  of  normal  pelvis  in  black,  of  contracted 
pelvis  in  red.) 

the  development  of  a  corresponding  curvature  in  the  other  bone. 
This  latter  force,  moreover,  is  greater  than  normal,  since  the 
underweighted  os  innominatum  becomes  excessively  curved,  owing 
to  the  diminution  of  the  inward  thrust  of  the  femur  on  that 
side.  In  this  way,  the  symphysis  pubis  is  pushed  and  pulled 
towards  the  sound  side,  and  comes  to  subtend  anteriorly  a  wide 
hollowed-out  portion  of  the  pelvic  cavity,  while  the  conjugata 
vera  becomes  correspondingly  displaced  from  the  mesial  plane. 
The  oblique  diameter  on  the  overweighted  side  is  considerably 
longer  than  its  fellow,  and  the  antero-posterior  diameter  drawn 
in  the  mesial  plane  of  the  body  is  much  diminished  in  length. 
Amongst  other  results  of  the  pressure  distribution,  we  may  notice 
that  the  overweighted  ilium  projects  further  back,  and  is  situated 
at  a  higher  level  than  the  opposite  ilium,  the  distance  from  its 
posterior  superior  spine  to  the  spines  of  the  sacrum  being  also 
diminished  as  compared  with  the  sound  side.  The  entire  bone 
has,  in  fact,  slipped  upwards  and  backwards  upon  the  ala  of  the 


764  THE  PATHOLOGY  OF  LABOUR 

sacrum.  Its  structure  is  abnormally  compact,  on  account  of  the 
increased  weight  which  it  has  to  sustain,  and  the  muscles  in 
relation  to  it  are  hypertrophied.  The  venter  ilii  on  the  affected 
side  is  unusually  flat,  lies  almost  vertically,  and  it  is  directed  more 
inwards  than  forwards.  The  opposite  os  innominatum,  on  the 
other  hand,  is  abnormally  slender,  and  the  muscles  and  ligaments 
in  relation  to  it  are  poorly  developed. 

The  Coxalgic  Pelvis. — This  term  is  applied  to  a  pelvis  which 
has  become  obliquely  deformed  as  a  result  of  unequal  lateral 
pressure  due  to  imperfect  or  abolished  use  of  one  lower  limb. 

The  most  common  morbid  causes  of  the  condition  are  tuber- 


Fig   317. — Oblique  Distortion  of  the  Pelvis.     The  Coxalgic  Pelvis. 
Note  the  diseased  condition  of  the  right  hip-joint. 

cular  disease  of  the  hip-joint,  some  variety  of  unilateral  talipes,  or 
congenital  shortening  of  one  leg.  Early  amputation  of  one  lower 
limb  may  produce  a  similar  result. 

In  cases  in  which  one  limb  is  shorter  than  the  other,  but  is  still 
capable  of  being  used,  the  pelvis  will  be  tilted  downwards  on  the 
diseased  side  in  a  compensatory  manner,  and  thus  increased 
weight  will  be  thrown  upon  the  shortened  limb.  In  consequence 
of  this,  changes  take  place  in  the  pelvis  exactly  similar  to  those 
which  have  been  described  in  the  kypho-scoliotic  pelvis.  More- 
over, scoliosis  of  the  lumbar  vertebrae,  with  the  convexity  directed 
towards  the  diseased  side,  almost  invariably  occurs,  and  con- 
tributes to  the  general  effect.  The  ala  of  the  sacrum  on  the 
diseased  side  remains  small,  and   is  driven  downwards  and  for- 


NAEGELE'S  PELVIS  765 

wards  into  the  pelvis.  The  innominate  bone  on  the  same  side  is 
unable  to  develop  its  normal  degree  of  curvature,  and  remains 
almost  straight  from  before  backwards ;  while  its  fellow  becomes 
excessively  curved,  and  pulls  the  symphysis  pubis  over  towards 
the  healthy  side,  towards  which  side,  in  consequence,  the  conju- 
gate diameter  is  directed.  The  oblique  diameter  of  the  diseased 
side  is  contracted,  and  the  opposite  oblique  diameter  is  lengthened. 
If,  however,  the  use  of  one  lower  limb  is  entirely  abolished,  the 
exactly  opposite  variety  of  obliquity  occurs.  In  these  cases,  all 
the  weight  of  the  body  is  necessarily  transmitted  through  the 
sound  limb,  the  muscles  and  bones  of  which  become  much  hyper- 
trophied.  The  os  innominatum  on  the  diseased  side  is  excessively 
hollowed  out,  and  the  symphysis  pubis  is  displaced  towards  that 
side.  The  bones  also  on  the  diseased  side  are  slender,  especially 
in  front,  and  the  venter  ilii  may  be  more  vertical  than  usual. 


Fig.  318.— The  Coxalgic  Pelvi?. 

Outline  of  brim.     (Outline  of  normal  pelvis  in  black,  of  contracted 
pelvis  in  red.) 

The  oblique  diameter  on  the  sound  side  is  diminished,  and  the 
opposite  oblique  diameter  is  lengthened.  It  is  only  in  rare  in- 
stances that  more  than  a  very  minor  degree  of  obliquity  is 
produced  by  any  form  of  coxalgia. 

The  Unilateral  Synostotic  Pelvis,  or  Pelvis  of  Naegele. 
— The  distinguishing  and  characteristic  feature  of  this  pelvis  is 
ankylosis  of  the  sacrum  with  the  ilium  on  one  side,  and  almost  com- 
plete atrophy  of  the  lateral  mass  of  the  sacrum  on  the  same  side. 

The  actual  cause  of  this  ankylosis  is  different  in  different  cases. 
In  the  majority,  it  is  probably  due  to  a  congenital  and  unilateral 
failure  of  the  centres  of  ossification  from  which  the  lateral  part 
of  the  sacrum  is  normally  developed.  This  causes  a  pronounced 
and  unilateral  narrowing  of  the  sacrum,  and  excessive  pressure 
is  therefore  thrown  upon  the  deformed  side.  This  pressure 
displaces  the  sacrum  downwards  and  forwards  on  that  side,  and 
ultimately  is  responsible  for  the  occurrence  of  synostosis  by  the 
atrophy  which  it  occasions  in  the  joint  surfaces.     In  other  cases, 


766 


THE  PATHOLOGY  OF  LABOUR 


it  is  probable  that  the  sacrum  in  the  first  instance  becomes 
slightly  displaced  forwards  on  one  side,  as  a  result  of  injury, 
and  then  becomes  ankylosed  in  its  new  position,  thus  preventing 
further  lateral  development.  In  a  few  cases,  inflammation  of 
the  sacro-iliac  joint  may  be  the  cause  of  both  displacement  and 
synostosis. 

The  ankylosis  generally  takes  place  in  early  life,  and  there- 
fore leads  to  considerable  pelvic  deformity.  Should  it  occur  at 
a  later  period,  but  before  the  skeleton  has  completed  its  develop- 
ment, a  lesser  degree  of  distortion  is  the  result. 


Fig.  319. — Oblique  Distortion  of  the  Pelvis.      The  Unilateral 
Synostotic  or  Naegele's  Pelvis. 


The  unequal  transmission  of  the  body-weight  is  the  mechanical 
result  of  the  fact  that  the  distance  from  the  middle  of  the  base  of 
the  sacrum  to  the  sacro-iliac  articulation  on  the  diseased  side  is 
less  than  the  distance  between  the  two  similar  points  on  the  sound 
side,  and  that  therefore  more  pressure  is  brought  to  bear  upon  the 
diseased  side,  the  muscles  and  ligaments  of  which  become  pro- 
portionately hypertrophied.  The  inward  thrust  of  the  head  of 
the  femur  is  therefore  increased  on  the  ankylosed  side,  and, 
at  the  same  time,  the  ankylosis  renders  the  leverage  exerted  by 
the  outward  pull  of  the  sacro-iliac  ligaments  entirely  nugatory, 
although  the  growth  of  the  os  innominatum  itself  is  not  interfered 
with. 


Plate  IX. — Skiagram  of  a  Unilateral  Synostotic  or  Naegele's 

Pelvis. 

Note  the  absence  of  the  right  sacro-iliac  joint,  and  of  the  right  lateral  mass 
of  the  sacrum.  (From  a  skiagram  taken  by  Dr.  W.  S.  Haughton  of 
a  patient  who  was  confined  in  the  Maternity  Ward  of  Dr.  Steevens' 
Hospital.) 

\Tofacc p.  766. 


NAEGELE'S  PELVIS  767 

The. general  result  of  these  changes  is  similar  to  that  which  has 
been  already  described  in  the  other  forms  of  oblique  pelvis,  but  the 
oblique  distortion  is  usually  much  more  pronounced.  The  pro- 
montory of  the  sacrum  is  depressed  and  driven  forwards  on  the 
diseased  side,  and  the  front  of  the  sacrum  looks  towards  the  same 
side.  The  ankylosed  os  innominatum  is  almost  straight  from 
before  backwards,  and  is  displaced  upwards.  The  transverse 
diameter  of  the  pelvis  is  shortened  throughout  the  whole  extent 
of  the  cavity,  but  especially  at  the  outlet  by  the  inward  and 
backward  projection  of  the  tuber  ischii.  The  ischial  spine  on 
the  diseased  side  forms  a  marked  inward  projection. 

The  healthy  os  innominatum  is  comparatively  slender,  and  is 
hollowed  out  into  a  marked  concavity,  especially  at  its  anterior 
part.  The  symphysis  pubis  is  drawn  over  to  the  sound  side  and 
subtends  the  wider  division  of  the  pelvic  cavity,  so  that  the  shape 


Fig.  320. — Naegele's  Pelvis. 

Outline  of  brim.     (Outline  of  normal  pelvis  in  black,  of  contracted 
pelvis  in  red.) 

of  the  inlet  becomes  that  of  an  obliquely  placed  oval,  the  long 
diameter  of  which  approximately  corresponds  to  the  oblique 
diameter  drawn  from  the  synostosed  sacro-iliac  joint  to  the 
opposite  acetabulum,  and  which  is  cut  transversely  by  the  opposite 
and  shortened  oblique  diameter.  The  conjugata  vera  is  often 
slightly  increased  in  length.  The  venter  ilii  on  the  diseased  side 
is  almost  vertical.  It  is  flat,  and  looks  almost  directly  in- 
wards, while  the  posterior  superior  iliac  spine  overlaps  the  back 
of  the  sacrum,  and  approaches  very  close  to  the  middle  line  of 
the  back. 

Some  slight  scoliosis  in  the  lumbar  region  is  usually  present, 
the  convexity  of  the  curve  being  directed  towards  the  diseased 
side. 

Symptoms. — The  symptoms  of  oblique  distortion  of  the  pelvis 
are  those  common  to  all  forms  of  contraction.  Their  intensity 
depends  upon  the  degree  of  contraction  present,  and  this  is 
estimated  not  by  the  length  of  the  conjugate  diameter,  as  in  the 


768  THE  PATHOLOGY  OF  LABOUR 

varieties  of  contraction  with  which  we  have  dealt,  but  by  the 
length  of  the  shorter  of  the  two  oblique  diameters. 

When  the  degree  of  distortion  is  not  such  as  to  prevent  the 
passage  of  the  head,  the  latter  usually  engages  with  its  sagittal 
diameter  corresponding  to  the  long  oblique  diameter  of  the  pelvis 
— i.e.,  that  running  from  the  sacro-iliac  joint  on  the  deformed  side 
to  the  opposite  pectineal  eminence.  If,  however,  the  distortion  is 
extreme  and  the  sacro-cotyloid  distance  on  the  deformed  side  is  so 
short  that  the  head  cannot  pass  into  that  portion  of  the  pelvic 
cavity  which  lies  behind  it,  the  oblique  diameter  on  the  deformed 
side,  though  actually  the  longer,  is  practically  the  shorter.  In 
such  a  case,  the  pelvis  for  practical  purposes  assumes  the  form  of 
the  generally  contracted  pelvis,  and  the  mechanism  of  labour  is 
similar  (Spiegelberg).  The  head  enters  the  brim  in  a  position  of 
marked  flexion,  its  sagittal  suture  running  obliquely  or  trans- 
versely. The  further  progress  of  the  case  depends  on  whether 
the  degree  of  contraction  increases  or  diminishes  towards  the 
outlet.  The  passage  of  the  head  at  the  outlet  is  easiest  when  the 
sagittal  suture  corresponds  with  the  anatomically  shorter  oblique 
diameter,  as  the  obliquity  tends  to  become  reversed  towards 
the  outlet.  An  after-coming  head,  however,  passes  more  easily 
through  the  pelvis  when  the  occiput  is  directed  towards  the  wide 
side  of  the  pelvis  (Spiegelberg). 

Diagnosis. — Inspection  of  the  patient  will,  as  a  rule,  show  that 
the  sides  of  her  body  are  asymmetrical,  and  a  vaginal  examina- 
tion, if  carefully  made,  will  enable  the  unilateral  flattening  of  the 
pelvis  to  be  recognised.  External  measurements  show  that  the 
iliac  bone  on  one  side  is  higher  than  normal,  and  that  consequently 
one  anterior  superior  spine  lies  on  a  higher  level  than  does  the 
other  ;  that  the  iliac  crest  rises  higher  on  one  side  than  on  the 
other  ;  that  the  posterior  superior  spines  are  unequally  distant 
from  the  middle  line ;  and  that  one  spine  projects  further  back- 
wards than  does  the  other  (Spiegelberg*;.  Internal  examina- 
tion and  measurements  show  that  the  pubic  arch  is  directed 
somewhat  to  one  side  instead  of  straight  forward ;  that  one  hori- 
zontal pubic  ramus  does  not  bulge  as  far  forward  as  is  normal ; 
and  that  the  corresponding  ilio-pectineal  line  is  more  or  less 
straightened,  while  the  promontory  can  only  be  reached  with 
difficulty,  if  at  all.  When  the  promontory  can  be  reached,  it 
appears  to  deviate  from  the  middle  line,  and  not  to  face  the 
symphysis  (Spiegelberg).  The  condition  of  the  pelvis  is  most 
likely  to  attract  attention  in  the  case  of  a  kypho-scoliotic  or 
coxalgic  pelvis,  on  account  of  the  obvious  lesions  that  are  present 
in  the  spinal  column,  the  hip-joint,  or  the  lower  limb.  The 
Naegele  pelvis  due  to  disease  of,  or  in  the  neighbourhood  of, 
the  sacro-iliac  joint  can  be  recognised  by  the  following  measure- 
ments given  by  Naegelef  for  the  purpose  : — 

*  Op.  cit.,  vol.  ii.,  p.  102. 

f  '  Das  Schrag  Verengte  Becken,'  Maintz,  1839. 


TRANSVERSELY  CONTRACTED  PELVIS  769 

(1)  The  distance  from  the  ischial  tuberosity  on  the  deformed 
side  to  the  posterior  superior  spine  on  the  opposite  side  is  shorter 
than  its  fellow. 

(2)  The  distance  from  the  anterior  superior  spine  on  the  de- 
formed side  to  the  spinous  process  of  the  last  lumbar  vertebra  is 
shorter  than  its  fellow. 

(3)  The  distance  from  the  anterior  superior  spine  on  the  deformed 
side  to  the  posterior  superior  spine  on  the  opposite  side  is  shorter 
than  its  fellow. 

(4)  The  distance  from  the  great  trochanter  on  the  deformed  side 
to  the  posterior  superior  spine  on  the  opposite  side  is  shorter  than 
its  fellow. 

(5 )  The  distance  from  the  posterior  superior  spine  on  the  deformed 
side  to  the  lower  edge  of  the  symphysis  is  longer  than  its  fellow. 

Spiegelberg  considered  that  these  measurements  are  not  of  any 
great  value  in  cases  of  slight  deformity,  and  that  in  cases  of  con- 
siderable deformity  a  diagnosis  is  best  arrived  at  by  introducing 
the  hand  into  the  vagina,  and  noting  the  distances  between  the 
apex  of  the  sacrum  and  the  ischial  spines  on  each  side,  and 
between  the  middle  of  the  promontory  and  the  upper  and  posterior 
portion  of  the  floor  of  the  acetabulum  (the  sacro-cotyloid  distance) 
on  each  side. 

Treatment. — If  the  degree  of  contraction  is  slight,  the  head  may 
mould  successfully  through  the  pelvis.  If  it  fails  to  do  so,  per- 
foration must  be  performed.  Spiegelberg  particularly  warned  us 
against  the  application  of  the  forceps  or  the  performance  of  version 
under  any  circumstances.  If  the  case  is  seen  sufficiently  early, 
and  if  the  degree  of  narrowing  is  not  very  great,  premature  labour 
should  be  induced.  In  other  cases,  Csesarean  section  should  be 
performed  at  term. 

Prognosis. — To  judge  by  Litzmann's  statistics,  the  prognosis  in 
this  form  of  contraction  is  very  serious  for  both  mother  and  foetus. 
According  to  this  writer,  out  of  28  mothers,  22  died  during  their 
first  confinement;  out  of  41  labours,  only  6  passed  off  spon- 
taneously, and  of  these  5  were  in  the  same  individual  ;  out  of 
41  children,  only  10  were  born  alive,  and  of  these  6  had  the  same 
mother.  These  figures  cannot,  however,  hold  good  for  the  present 
day,  save  in  cases  in  which  the  existence  and  degree  of  the 
contraction  are  not  recognised,  as  Caesarean  section  is  usually 
clearly  indicated,  and  will  yield  a  very  much  reduced  mortality. 

Transversely  Contracted  Pelvis. 

A  transversely  contracted  pelvis  is  a  pelvis  in  which  there  is 
marked  symmetrical  transverse  narrowing  of  the  pelvis. 

Varieties. — Two  varieties  of  transversely  contracted  pelvis  are 
met  with  : — 

(1)  The  bilateral  synostotic,  or  Robert's  pelvis. 

(2)  The  kyphotic  pelvis. 

49 


77o 


THE  PATHOLOGY  OF  LABOUR 


The  kyphotic  pelvis  partakes  of  the  nature  of  both  a  trans- 
versely contracted  pelvis  and  of  a  funnel-shaped  pelvis.  In 
consequence,  it  is  allocated  to  different  classes  of  contracted 
pelvis  by  different  writers.  Litzmann  classifies  it  as  a  funnel- 
shaped  pelvis,  but  we  prefer  to  follow  Spiegelberg  and  to  classify 
it  as  a  transversely  contracted  pelvis. 

We  shall  discuss  Robert's  pelvis  and  the  kyphotic  pelvis 
separately. 

Robert's  Pelvis. — This  pelvis  was  first  described  by  Robert* 
in  1842,  and  is  generally  known  by  his  name.  It  is  the  result 
of  bilateral  synostosis  of  the  sacro-iliac  joint,  similar  to  that 
which  occurs  on  one  side  in  the  oblique  pelvis  of  Naegele. 


Fig.  321. — Transverse  Contraction  of  the  Pelvis. 
Robert's  Pelvis. 

The  union  between  the  ilium  and  sacrum  takes  place  at  an 
early  period  of  life,  and  thus  causes  arrest  in  development  of  the 
lateral  masses  of  the  sacrum,  so  that  this  bone  is  very  narrow  at 
its  upper  part,  and  is,  indeed,  of  almost  the  same  width  through- 
out. Its  vertical  curvature  is  lessened  or  absent,  and  its  trans- 
verse curvature  is  replaced  by  a  forward  convexity,  produced  by 
the  action  of  the  body-weight  when  the  bone  is  in  a  more  or  less 
plastic  condition,  and  after  ankylosis  has  taken  place.  The 
osseous  union  with  the  ilia  prevents  the  normal  outward  leverage 

*  '  Beschreibung  eines  im  hochsten  Grade  querverengten  Bekens,'  etc., 
Karlsruhe  v.  Freiburg,  1842. 


ROBERTS  PELVIS  771 

of  the  sacrum  on  these  bones,  and  thus  the  os  innominatum  on 
each  side  pursues  an  almost  straight  course  from  behind  forwards, 
and  the  ilio-pectineal  lines,  which  are  often  unusually  prominent, 
are  almost  parallel  in  their  posterior  part.  The  antero-posterior 
diameter  is  of  normal  length  or  else  is  slightly  diminished, 
and  the  oblique  diameters  are  rather  shorter  than  normal  ;  but 
the  most  marked  change  is  the  contraction  of  the  transverse 
diameter,  which  may  be  reduced  at  the  pelvic  brim  to  less  than 
three  inches  in  length.  This  contraction,  moreover,  is  present 
throughout  the  whole  pelvic  canal,  and  increases  at  the  outlet 
in  consequence  of  the  great  inversion  of  the  tubera  ischii.  The 
inlet  is  triangular  in  shape,  the  narrow  base  being  formed  by 
the  sacral  promontory  and  the  apex  lying  in  front  at  the  sym- 
physis pubis.  Often,  the  outlet  is  merely  an  antero-posterior  slit 
between  the  ischia,  so  that  the  cavity  of  the  pelvis  from  above 
downwards  is  wedge-shaped. 

In  front,  the  descending  rami  of  the  pubes  are  almost  vertical 


Fig.  322. — Robert's  Pelvis. 

Outline  of  the  brim.     (Outline  of  normal  pelvis  in  black,  of  contracted 
pelvis  in  red.) 

« 

in  direction,  and  meet  above  at  a  very  acute  angle.  The  bodies 
of  the  pubic  bones  look  more  outwards  than  forwards.  The 
iliac  fossae  are  flat,  more  vertical  than  normal,  and  are  directed 
forwards,  and  the  curvature  of  the  iliac  crests  is  diminished. 

The  essential  cause  of  this  deformity  is  probably  identical  with 
that  which  leads  to  unilateral  synostosis,  such  as  is  found  in  the 
pelvis  of  Naegele.  Without  doubt,  in  a  majority  of  cases,  the 
failure  of  development  of  the  alae  of  the  sacrum  is  to  be  referred 
to  a  congenital  anomaly,  by  which  the  ossific  centres,  from  which 
these  portions  of  the  bone  are  normally  formed,  fail  to  appear, 
and  the  ankylosis  then  takes  place  secondarily.  In  other  cases, 
the  ankylosis  may  be  primary,  and  occur  as  the  result  of  some 
disease  affecting  the  sacro-iliac  joint,  or  else  rapid  ossification, 
and  consequent  ankylosis,  may  have  occurred  in  the  bones  which 
were  from  the  first  united  by  cartilage,  owing  to  the  non-appear- 
ance of  the  joint  cavity. 

49—2 


772 


THE  PATHOLOGY  OF  LABOUR 


Other  writers  believe  that  in  all  cases  the  sacrum  is  primarily 
displaced  forwards  in  early  life  from  some  unknown  cause,  possibly 
injury,  and  that  synostosis  then  results,  due  to  non-apposition  of 
joint  surfaces.  This  last  theory  is  in  some  degree  supported  by 
the  fact  that  the  sacrum  is  always  sunk  deeply  between  the  iliac 
bones,  and  that  occasionally  the  displacement  forwards  is  more 
marked  on  one  side.  The  approximation  of  the  posterior  superior 
iliac  spines  behind  the  sacrum  forms  an  important  diagnostic 
addition  to  the  results  obtained  by  internal  pelvimetry. 

Synostosis  of  both   sacro-iliac   joints    in  adult  life  is  not  un- 


Fig.  323. — Transverse  Contraction  of  the  Pelvis. 

Pelvis. 


The  Kyphotic 


common,  and  is  especially  frequent  in  Ireland,  as  a  result  of 
arthritis  deformans.  It  does  not  give  rise  to  any  deformity,  but 
might  possibly  retard  labour  by  rendering  the  nutation  of  the 
sacrum  impossible. 

Frequency. — Robert's  pelvis  is  one  of  the  rarest  forms  of  pelvic 
contraction  met  with.  Only  about  eight  cases  of  this  deformity 
•have  been  described. 

Symptoms. — The  effect  of  Robert's  pelvis  on  the  mechanism  of 
labour  is  similar  to  that  of  any  of  the  extreme  degrees  of  con- 
traction. The  foetus  can  never  be  expelled  by  the  natural  efforts,  and 
in  many  cases  it  is  most  difficult  to  extract  it  even  by  craniotomy. 

Diagnosis. — The  external  examination    of   the  patient  reveals 


THE  KYPHOTIC  PELVIS  773 

marked  shortening  of  the  inter-spinous  and  inter-cristal  distances, 
and  of  all  the  transverse  measurements  of  the  pelvis.  Vaginal 
examination  will  at  once  make  evident  the  shortness  of  the 
transverse  diameters  of  the  true  pelvis,  and  the  almost  parallel 
course  of  the  pubic  rami. 

Treatment. — If  possible,  Cesarean  section  should  be  performed 
in  all  cases.  If  this  course  cannot  be  adopted,  craniotomy  must 
be  performed. 

Prognosis. — The  prognosis  in  this  deformity  is  bad.  Of  the 
eight  cases  mentioned  by  Spiegelberg,  six  were  delivered  by 
Cesarean  section  and  two  by  perforation.     Both  the  latter  died. 

The  Kyphotic  Pelvis. — The  effect  on  the  pelvis  of  posterior 
curvature  of  the  vertebral  column  depends  upon  the  position  of 
the  curvature.  When  it  is  situated  in  the  lower  lumbar  or  lumbo- 
sacral region,  a  form  of  transversely  contracted  pelvis  is  produced, 


324. — The  Kyphotic  Pelvis. 


A,  Outline  of  brim  ;  B,  sagittal  section.     (Outline  of  normal  pelvis 
black,  of  contracted  pelvis  in  red.) 

the  amount  of  deformity  varying  inversely  with  the  height  of  the 
curvature  above  the  pelvis.  As  a  rule,  in  these  cases  a  slight 
compensatory  lordosis  exists  in  the  dorsal  region.  The  most 
common  cause  of  the  kyphosis  is  tubercular  caries  of  the  vertebral 
bodies,  and,  in  some  cases,  the  base  of  the  sacrum  itself  may  be 
involved.  Most  of  the  pelvic  changes  are  due  to  the  abnormal 
direction  in  which  the  body-weight  is  transmitted  to  the  sacrum 
—namely,  from  above  downwards  and  backwards  ;  but  Freund 
asserts  that  some  of  the  deviations  from  the  normal  adult  type 
are  due  to  the  persistence  of  the  foetal  or  infantile  form,  and  that 
secondary  changes  occur  later  as  a  result  of  the  kyphosis. 

On   examining  such  a  pelvis,   it  is    found  that  the    posterior 


774  THE  PATHOLOGY  OF  LABOUR 

curvature  has  drawn  the  base  of  the  sacrum  backwards,  causing 
it  to  rotate  on  its  transverse  axis,  so  that  the  apex  is  directed 
more  forwards  than  usual,  and  the  long  axis  of  the  bone  is  situated 
almost  in  the  vertical  plane.  The  centre  of  gravity  of  the  body 
is  also  displaced  backwards,  and  the  body-weight  is  thus  pre- 
vented'from  exerting  its  normal  influence  in  driving  the  sacrum 
forwards  and  downwards  into  the  pelvis.  Its  influence  in  driving 
it  directly  downwards  is,  however,  increased,  and  thus  the  sacrum 
becomes  sunk  deeply  between  the  iliac  bones.  At  the  same  time, 
the  obliquity  of  the  pelvis  is  diminished  in  order  that  the 
equilibrium  of  the  body  may  be  maintained,  and  an  increased 
strain  is  thrown  upon  the  ilio-femoral  ligaments,  as  is  manifested 
by  the  prominence  of  the  anterior  inferior  iliac  spines.  The 
failure  of  the  sacrum  to  sink  forwards  lessens  the  strain  upon 
the  sacro-iliac  ligaments,  and  in  consequence  diminishes  their 
leverage  action  upon  the  ossa  innominata,  and  leaves  the  inward 
thrust  of  the  heads  of  the  femora  uncompensated.  The  result  of 
this  is  that  both  innominate  bones  are  less  curved  than  normal, 
and  that  both  the  conjugate  and  oblique  diameters  of  the  brim  are 
widened,  while  at  the  same  time  a  moderate  degree  of  transverse 
contraction  is  produced. 

At  the  outlet,  both  conjugate  and  transverse  diameters  are 
contracted,  the  former  owing  to  the  forward  movement  of  the 
lower  end  of  the  sacrum,  and  the  latter  in  consequence  of  inversion 
of  the  tubera  ischii.  The  pelvis  therefore  has  a  distinctly  funnel 
shape. 

Amongst  other  peculiarities  of  this  type  of  pelvis,  we  may  note 
that  the  sacrum  is  smaller  transversely  than  normal,  while  its 
transverse  concavity  is  increased.  The  pull  upon  it  from  behind 
and  above  increases  its  length  and  diminishes  its  vertical  curvature. 
The  curvature  of  the  iliac  crests  is  diminished,  so  that  their 
anterior  spines  are  widely  separated.  On  the  other  hand,  the 
narrowness  of  the  sacrum  causes  the  posterior  superior  iliac 
spines  to  become  approximated.  The  pubis  is  narrow  and  some- 
what pointed  anteriorly,  instead  of  being  flat,  and  the  sub-pubic 
angle  is  narrowed.  When  the  lumbar  kyphosis  is  unusually 
marked,  the  upper  arc  of  the  curve  may  overhang  the  pelvic 
inlet  in  such  a  manner  as  to  almost  completely  roof  it  over. 

In  those  cases  in  which  kyphosis  is  situated  high  up  in  the 
dorsal  region,  little  or  no  effect  is  produced  on  the  pelvis,  or  else  a 
compensatory  lumbar  lordosis  may  exist,  and  this,  overhanging  the 
pelvis,  produces  great  antero-posterior  contraction  just  above  the 
brim,  giving  the  pelvis  something  of  the  appearance  found  in 
spondylolisthesis.  The  pelvic  obliquity  is  at  the  same  time 
increased,  and  thus  an  additional  obstacle  to  the  passage  of  the 
child  is  introduced. 

Frequency.—  A  kyphotic  pelvis  is  of  more  common  occurrence 
than   is  the  variety  we  have  just  discussed.      Klein  *    collected 

*   '  Die  Geburt  beim  Kyphotischen  Becken,'  Archiv  f.  Gyn.,  1896,  1.  1-128. 


THE  KYPHOTIC  PELVIS 


775 


85  cases  amongst  511,360  patients,  and  he  believed  that  its  true 
frequency  was  greater  than  these  figures  show. 

Symptoms. — In  kyphotic  pelvis,  the  foetus  usually  lies  with  the 
back  posterior,  probably  due  in  some  cases  to  the  absence  of 
the  lumbar  curve  of  the  spine,  and  in  others  to  the  pendulous 
abdomen  (Champneys*)  and  the  consequent  absence  of  the  usual 
adaptation  between  the  concavity  of  the  abdominal  surface  of 
the  foetus  and  the  convexity  of  the  lumbar  spine.  Internal 
rotation  occurs  earlier  than  is  normal,  in  consequence  of  the 
action  of  the  narrowed  pelvic  outlet,  and  posterior  rotation  of  the 
occiput  is  common.  Where  the  kyphosis  is  very  low,  and  a 
sinking  in  of  the  bodies  of  the  vertebrae  has  resulted  from  their 
destruction  by  caries,  there  is  a  consequent  extreme  shortening 


Fig.  325. — A  Case  of  Spondylizema. 


of  the  conjugate  diameter,  and  the  head  is  unable  to  enter  the 
brim.  This  condition  is  usually  known  as  pelvis  obtecta  (Fehlingf) 
or  spondylizema;  (Hergott§). 

Diagnosis. — The  hump-backed  appearance  of  the  patient  suggests 
at  once  the  possibility  of  the  presence  of  a  kyphotic  pelvis.  On 
vaginal  examination  the  narrowing  of  the  outlet  will  be  apparent, 
and  this  can  be  confirmed  by  measurement.  According  to 
Spiegelberg,  the  distance  between  the  anterior  superior  spines  is 
increased,  the  symphysis  is  high  and  prominent,  the  promontory 
far  back  and  difficult  to  reach,  the  distances  between  the  ischial 

*  '  Obstetrics  of  the  Kyphotic  Pelvis,'  Trans.  Obstet.  Soc.  Lond.,  vol.  xxv. , 
p.  166. 

f  '  Pelvis  Obtecta,'  Archiv  f.  Gyn.,  1872,  iv.  1-33. 

%  Arch,  de  Tocologie,  fourth  year,  1877,  1.  65,  and  Annal.  Gyncc.,  vii.,  1877. 

§  awovdv\os,  a  vertebra  ;  t^ixa,  a  sinking. 


776 


THE  PATHOLOGY  OF  LABOUR 


spines  and  the  ischial  tuberosities  are  both  diminished,  and  the 
pubic  arch  is  narrow. 

Treatment. — If  the  contraction  is  not  very  great,  the  expulsion 
of  the  foetus  may  be  left  to  the  natural  efforts,  and  if  these  fail  to 
effect  delivery,  an  attempt  may  be  made  to  extract  the  foetus  with 
the  forceps.  If  this  fails,  craniotomy  must  be  performed.  Version 
is  contra-indicated,  as  the  extraction  of  the  after-coming  head 
would  be  rendered  most  difficult  by  the  narrow  outlet,  and,  if 
it  could  not  be  extracted,  its  perforation  would  be  also  difficult. 
In  some  cases,  it  may  be  advisable  to  induce  premature  labour, 


Fig.  326. — The  Funnel-shaped  Pelvis. 


and,  in  extreme  degrees  of  contraction,  Caesarean  section  must  be 
performed. 

Prognosis. — The  prognosis  of  this  form  of  contraction  is  serious 
for  both  mother  and  foetus.  Champneys*  estimates  the  maternal 
mortality  at  28*1  per  cent.,  the  foetal  mortality  at  40'6  per  cent. 


Funnel-shaped  Pelvis. 

In  addition  to  the  kyphotic  pelvis  which  has  been  just  described, 
and  which  presents  the  appearance  of  an  inverted  wedge  or  funnel, 
there  is  another  type  of  pelvis  found  independent  of  spinal  curva- 
ture, to  which  the  term  '  funnel-shaped  pelvis  '  is  applied. 

This  form  of  pelvis  is  characterised  by  the  fact  that,  while  the 
*  Op.  cit.,  p.  187. 


THE  FUNNEL-SHAPED  PELVIS 


777 


various  diameters  of  the  brim  are  normal,  or  at  most  deviate  but 
slightly  from  the  normal,  on  tracing  them  down  to  the  outlet 
they  are  found  to  undergo  a  gradual  diminution  in  length.  This 
diminution  usually  affects  one  diameter  in  a  more  marked  degree 
than  the  other,  and  has  thus  led  to  a  division  of  this  variety  of 
pelvis  into  transversely  contracted  funnel-shaped  pelves,  and 
antero- posteriorly  contracted  funnel-shaped  pelves.  Of  these, 
the  former  is  the  more  common,  and  is  also  the  more  important 
from  an  obstetrical  point  of  view.  It  usually  possesses  male 
characteristics,  and  is,  in  fact,  one  of  the  varieties  of  the  virile 
pelvis  of  some  authors.  The  bones  are  rather  massive  and 
irregular,  the  pubic  arch  is  narrow,  and  the  depth  of  the  pelvic 
cavity  increased.  The  bodies  of  the  ischia  converge  below,  and 
the  ischial  spines  project  prominently  inwards.      The  sacrum   is 


The  Funnel-shaped  Pelvis. 


A,  Outline  of  brim  ;  B,  sagittal  section.     (Outline  of  normal  pelvis  in 
black,  of  contracted  pelvis  in  red.) 


narrow,  is  longer  than  normal,  and  its  vertical  curvature  is 
lessened.  Above,  it  is  placed  rather  far  back  between  the  iliac 
bones  ;  and,  below,  it  projects  forwards. 

The  aetiology  of  the  funnel-shaped  pelvis  is  unknown.  Its 
general  appearance  suggests  that  the  pelvis  has  failed  to  develop 
into  the  adult  form,  and  the  position  of  the  sacrum  seems  to  show 
that  at  an  early  period  of  life  the  body-weight  was  transmitted  in 
an  abnormal  direction,  as  occurs  in  the  kyphotic  pelvis.  No  cause 
for  this  mal-development  or  for  the  position  of  the  sacrum  has, 
however,  been  yet  discovered. 

Frequency. — The  true  funnel-shaped  pelvis  is  of  exceedingly  rare 
occurrence.  It  is  probably  more  common  on  the  Continent  than 
in  these  countries. 


778  THE  PATHOLOGY  OF  LABOUR 

Symptoms. — As  the  diameters  of  the  brim  are  unaffected  in  this 
class  of.  deformity,  there  is  nothing  to  prevent  the  head  from 
entering  the  brim.  The  farther  it  descends  into  the  pelvic  cavity, 
however,  the  greater  becomes  the  obstruction  to  its  passage,  and 
finally  it  is  arrested  before  it  reaches  the  pelvic  floor.  If  labour 
is  then  allowed  to  continue,  the  head  may  become  deeply  marked 
by  the  pressure  of  the  ischial  spines.  The  other  symptoms  are 
similar  to  those  met  with  in  generally  contracted  pelvis. 

Diagnosis.  —  The  diagnosis  of  this  class  of  pelvis  is  difficult. 
Its  existence  will  be  seldom  suspected  in  cases  of  slight  deformity 
until  the  head  is  found  to  be  arrested  at  the  outlet.  In  cases 
of  more  marked  deformity,  vaginal  examination  may  reveal 
the  narrowness  of  the  pubic  arch,  the  slight  divergence  of  the 
descending  rami  of  the  pubic  bones,  and  the  diminished  distance 
between  the  ischial  tuberosities  (Spiegelberg).  A  definite  diagnosis 
can  be  made  by  measuring  the  antero-posterior  and  transverse 
diameters  of  the  pelvic  outlet,  as  has  been  described. 

Treatment. — If  the  contraction  of  the  outlet  is  slight,  it  may  be 
possible  to  extract  the  foetus  with  the  forceps.  If,  however,  the 
contraction  is  considerable,  nothing  is  to  be  gained  by  so  doing, 
as  the  pressure  of  the  pelvic  bones  on  the  head  will  bring  about 
the  death  of  the  foetus.  In  such  cases,  there  is  no  alternative 
save  to  perforate  the  head.  In  subsequent  labours,  the  induction 
of  premature  labour  may  be  successful  in  medium  degrees  of 
contraction,  but,  in  serious  degrees,  nothing  but  Caesarean  section 
will  be  of  any  avail. 

Prognosis. — The  prognosis  is  extremely  bad  for  the  child,  as  the 
nature  and  degree  of  the  contraction  is  rarely  recognised  until  it 
is  too  late  to  adopt  any  treatment  other  than  craniotomy.  It  is 
also  serious  for  the  mother,  as  the  condition  may  not  be  recognised 
and  labour  be  allowed  to  continue  too  long. 

Irregularly  Compressed  Pelvis. 

The  irregularly  compressed  or  triradiate  pelvis  is  one  in  which 
the  weight  of  the  body,  transmitted  through  the  spinal  column 
and  the  femora  and  acting  upon  bones  softened  by  disease,  dis- 
places the  promontory  and  the  acetabula  inwards,  and  so  produces 
gross  distortion  of  the  pelvis. 

Varieties. — Two  varieties  of  irregularly  compressed  pelvis  are 
met  with  : — 

(i)  The  osteo-malacic  triradiate  pelvis. 
(2)  The  rachitic  triradiate  pelvis. 

Frequency. — Both  these  forms  of  pelvis  are  exceedingly  rare  in 
these  countries.  The  rachitic  form  demands  for  its  production  the 
presence  of  rickets  of  an  advanced  degree  which,  fortunately,  is 
now  seldom  met  with,  while  osteo-malacia  is  practically  an  un- 
known disease. 


THE  OSTEO-MALACIC  TRIRADIATE  PELVIS  779 

The  Osteomalacic  Tkiradiate  Pelvis. — Osteomalacia  is  a 
disease  of  the  bones  which  is  excessively  rare  in  this  country 
and  in  America,  but  which  is  found  with  considerable  frequency 
in  certain  parts  of  Europe,  especially  in  low-lying,  damp  situa- 
tions. It  very  seldom  occurs  before  adult  life,  and  much  more 
frequently  attacks  women  than  men.  It  is  said  to  be  as  rare  in 
nulliparous  women  as  in  men,  and  thus  appears  to  be  in  some 
way  definitely  related  to  pregnancy.  Indeed,  it  most  often  appears 
first  during  the  period  of  gestation,  and  lasts  till  the  puerperium, 
when,  if  the  patient  does  not  suckle  her  infant,  slight  recovery 
may  set  in  till  the  onset  of  the  next  pregnancy,  at  the  com- 
mencement of  which  there  is  again,  as  a  rule,  a  marked  increase 
in  the  disease. 

Various  theories  have  been  advanced  regarding  the  aetiology  of 
osteo-malacia,  some  writers  believing  that  it  is  bacterial  in  origin, 
and  others  that  it  is  due  to  the  presence  of  lactic  acid  in  the  bones  ; 
but,  with  the  exception  of  the  fact  that  it  is  known  to  occur 
under  conditions  which  tend  to  lower  the  general  vitality,  such  as 
insufficient  proteid  diet  and  living  in  damp,  cold  climates,  nothing 
is  known  with  any  certainty.  That  something  more  than  these 
is  needed  to  produce  the  disease  is  proved  by  the  fact  that  in 
Ireland  a  large  percentage  of  the  peasantry  live  under  such 
conditions  ;  frequently  recurring  pregnancy  is  the  rule,  and  many 
of  the  women  lactate  during  almost  the  entire  period  of  their 
pregnancy,  and  yet  the  disease  is  practically  unknown.  In  those 
places  in  Europe  where  it  occurs,  the  increase  that  is  noted  in 
its  severity  during  pregnancy  is  probably  to  be  accounted  for  by 
the  demands  made  on  the  maternal  organism  during  that  period 
to  provide  for  the  building  up  of  the  foetal  skeleton.* 

The  essential  pathological  factor  met  with  in  the  disease  is  a 
chronic  rarefying  myelitis  and  osteitis,  which  cause  a  gradual 
absorption  of  the  bony  trabeculae  in  the  cancellous  parts.  The  trabe- 
cular are  at  first  replaced  by  a  form  of  osteoid  tissue  devoid  of  cal- 
cium salts,  but,  later,  they  become  infiltrated  with  a  vascular  granu- 
lation tissue  chiefly  composed  of  small  round  cells,  and  completely 
disappear,  so  that  on  cutting  into  the  bone  it  appears  to  be  entirely 
composed  of  a  semi-solid  and  reddish  pulp.  The  medullary  canals  of 
the  long  bones  become  enlarged,  and  the  compact  tissue  is  also  in 
great  part  absorbed,  the  process  of  absorption  commencing  around 
the  vessels  in  the  Haversian  canals  and  gradually  extending.  A 
thin  layer  of  compact  tissue,  however,  always  remains  persistent 
immediately  under  the  periosteum.  In  advanced  cases,  the  bones 
become  quite  flexible,  and  can  readily  be  indented  by  slight 
pressure.  Sometimes,  the  bones  are  universally  attacked,  but,  in 
pregnant  women,  the  disease  is  often  most  marked  in  the  pelvis  and 
the  vertebral  column.  The  changes  which  take  place  in  the  shape 
of  the  pelvis  are  the  result  of  the  pressure  and  counter-pressure  of 
the  body-weight,  both  in  sitting  and  standing,  acting  upon  abnor- 
*  '  Text-book  of  Midwifery,'  Spiegelberg,  vol.  ii.,  p.  113. 


78o 


THE  PATHOLOGY  OF  LABOUR 


mally   softened    bones,   and   to  these  forces  must   be  added  the 
influence  of  muscular  contraction. 

In  the  early  stages,  the  patient  usually  continues  to  walk  and 
stand,  and  therefore  the  first  changes  to  appear  are  due  to  the 
pressure  of  the  heads  of  the  femora.  The  softened  condition  of 
the  bones  has  rendered  the  outward  leverage  action  of  the  ossa 
innominata  totally  ineffective,  and  therefore  the  tendency  of  the 
femora  to  drive  the  acetabular  region  upwards,  backwards,  and 
inwards  is  unopposed.  As  the  bone  gradually  softens,  the  os 
innominatum  yields  at  its  weakest  parts,  which  are,  in  front, 
the  horizontal  ramus  of  the  pubis  above  and  the  ramus  of  the 
ischium  below,  and,  behind,  the  bar  of  bone  which  bounds  the 
great  sciatic  notch  above.     In  consequence,  the  acetabular  region 


Fig.  32S. — The  Compressed  or  Triradiate  Pelvis.     The  Osteo- 
malacic Pelvis. 


is  slowly  driven  in  towards  the  centre  of  the  pelvis.  Ulti- 
mately, the  two  acetabula  may  come  so  close  as  to  almost  touch 
one  another,  only  a  narrow  crevice  being  left  between  them. 
This  leads  anteriorly  into  a  slit-like  recess,  bounded  in  front 
by  the  symphysis  and  on  each  side  by  the  bodies  of  the  pubic 
bones,  which  have  become  so  sharply  bent  at  the  symphysis  as 
to  be  parallel  with  one  another  and  almost  to  lie  in  the  sagittal 
plane.  They  thus  form  a  marked  rostrum  or  beak  at  the  front  of 
the  pelvis. 

While  these  changes  have  been  going  on  in  the  anterior 
portion  of  the  pelvis,  the  pressure  upon  the  base  of  the  sacrum 
has  gradually  driven  this  bone  downwards  and  forwards  towards 
the  centre  of  the  pelvis,  and  at  the  same  time  has  bent  the  bone 
upon  itself,   so  that  its   vertical  curvature  is  increased  and   the 


THE  OSTEO-MALACIC  TRIRADIATE  PELVIS  781 

promontory  forms  a  very  marked  projection  at  the  inlet.  This 
projection,  together  with  the  projection  formed  by  the  backs  of 
the  displaced  acetabula,  give  to  the  inlet  the  characteristic  trira- 
diate  appearance.  The  normal  transverse  concavity  of  the 
sacrum  is  replaced  by  a  slight  anterior  convexity,  since  the  bodies 
of  the  sacral  vertebrae  are  more  displaced  than  the  alae.  The 
pull  of  the  lateral  masses  upon  the  ilia,  however,  causes  that 
portion  of  the  ilium  which  lies  posterior  to  the  sciatic  notch  to 
bend  forwards,  and  to  form  a  sharp  angular  recess  with  the 
anterior  portion  of  the  bone,  which,  as  we  have  already  seen,  is 
bent  inwards  ai  d  backwards  by  the  femur. 

In  the  early  stages,  the  outlet  of  the  pelvis  is  transversely  con- 
tracted by  the  inward  movement  of  the  bodies  of  the  ischia 
accompanying  the   acetabula.     Later,   the  effects  of  sitting  and 


A  B 

Fig.   329. — The  Osteomalacic  Pelvis. 

A,  Outline  of  brim  ;   B,  outline  of  outlet.     (Outline  of  normal  pelvis  in 
black,  of  contracted  pelvis  in  red.) 

lying  greatly  increase  the  contraction.  The  tubera  ischii  are 
inverted,  and  often  come  in  contact  with  one  another.  The 
descending  rami  of  the  pubis  descend  almost  vertically  and  in 
close  contact,  so  that  the  sub-pubic  angle  is  nearly  obliterated. 
Pressure  upon  the  apex  of  the  sacrum  and  upon  the  coccyx  causes 
them  to  bend  upwards  and  forwards  into  the  pelvis,  and,  in  some 
cases,  they  may  closely  approximate  the  sacral  promontory.  In 
all  cases,  the  contraction  at  the  outlet  is  further  advanced  than 
that  at  the  inlet.  The  obliquity  of  the  inlet  is  diminished, 
principally  as  a  result  of  the  upward  displacement  of  the  anterior 
portion  of  the  pelvic  ring. 

The  iliac  fossae  are  distorted  by  the  action  of  the  muscles 
attached  to  them  and  by  the  drag  of  the  posterior  sacro-iliac 
ligaments.     The  crest  becomes  greatly  curved,  and  the  anterior 


782 


THE  PATHOLOGY  OF  LABOUR 


superior  spines  are  approximated.  In  all  well-developed  cases, 
the  ilium  is  folded  almost  double  upon  itself,  and  the  fossa 
divided  by  a  deep  groove  into  a  posterior  part  which  looks 
forwards,  and  an  anterior  part  which  looks  backwards  and  in- 
wards. Frequently,  the  deformity  of  the  whole  pelvis  is  some- 
what asymmetrical,  owing  to  the  patient  lying  chiefly  on  one  or 
other  side,  or  else  to  the  development  of  an  early  lateral  curvature 
of  the  spinal  column  as  a  result  of  the  disease,  and  the  conse- 
quent unequal  distribution  of  weight  on  the  two  sides. 

Diagnosis. — The  diagnosis  can  be  readily  made  from  the  history 
and  appearance  of  the  patient  and  from  the  yielding  nature  of  the 


Fig.  330. 


—The  Compressed  or  Triradiate  Pelvis.     The  Rachitic 
Triradiate,  or  Pseudo-osteo-malacic  Pelvis. 


pelvic  bones.  The  last  can  be  best  determined  by  introducing 
the  entire  hand  into  the  vagina  while  the  patient  is  under  an 
anaesthetic  (Spiegelberg). 

Treatment. — Even  an  extreme  degree  of  contraction  of  the  pelvis 
in  this  condition  is  not  the  hopeless  barrier  to  the  passage  of  the 
foetus  that  it  would  at  first  appear  to  be,  as,  in  many  cases, 
the  bones-  are  so  soft  as  to  allow  an  actual  dilatation  of  the 
contracted  canal  during  labour.  In  such  cases,  the  foetus  may 
be  forced  through  the  pelvis  by  the  natural  efforts,  or  may  be 
capable  of  being  extracted  by  the  forceps.  In  many  other  cases, 
however,   even  of  a  dilatable  pelvis,  Cesarean  section  or   sym- 


THE  OSTEO-MALACIC  TRI RADIATE  PELVIS  7^3 

physiotomy  may  be  required.  In  thirty-two  cases  of  dilatable 
pelvis  collected  by  Hugenberger,*  Cesarean'  section  was  per- 
formed in  seven  cases  and  symphysiotomy  in  _  one  case,  other 
modes  of  artificial  delivery  were  adopted  in  sixteen  cases,  and 
only  eight  ended  spontaneously. 

If  the  patient  is  seen  during  pregnancy  and  if  the  bones  are 
yielding,  premature  labour  should  be  induced.  During  labour, 
an  attempt  must  be  made  to  estimate  the  degree  to  which  the 
bones  will  yield  by  introducing  the  hand  into  the  vagina  while 
the  patient  is  under  an  anaesthetic.  If  there  is  reason  to  believe 
that  the  pelvic  ring  will  dilate  sufficiently  to  allow  the  head  to 
pass,  delivery  should  be  left  for  as  long  as  possible  to  the  natural 
efforts,  and  then  an  attempt  made  to  deliver  by  the  forceps.  If 
this  fails,  craniotomy  will  be  necessary.  If  there  is  no  reason  to 
believe  that  the  head  can  pass,  Cesarean  section  must  be  per- 


A  B 

Fig.  331. — The  Rachitic  Triradiate  Pelvis. 

A,  Outline  of  brim  ;  B,  outline  of  outlet.     (Outline  of  normal  pelvis 
in  black,  of  contracted  pelvis  in  red.) 

formed.  Whether  at  the  same  time  the  ovaries  should  be  removed, 
or  a  hysterectomy  performed  with  a  view  to  curing  the  disease, 
is  still  unsettled  (Schaefferf). 

Prognosis. — The  prognosis  in  a  case  of  osteo-malacic  pelvis  is 
extremely  bad  for  both  mother  and  foetus.  In  the  thirty-two 
cases  already  referred  to,  and  which  were  all  cases  of  dilatable 
pelvis,  the  following  results  were  found  : — 

In  eight  cases  of  Caesarean  section  or  symphysiotomy,  the 
maternal  mortality  was  75  per  cent.,  the  fcetal  mortality  50  per 
cent.  In  sixteen  cases  in  which  other  methods  of  artificial 
delivery  were  adopted,  the  maternal  mortality  was  6-3  per  cent. 

*  Petrsb.  Med.  Zeitsch.,  iii.,  1872. 

f  '  Obstetric  Diagnosis  and  Treatment,'  p.  224. 


784  THE  PATHOLOGY  OF  LABOUR 

and  the  foetal  37-5  per  cent.  In  eight  cases  which  ended  spon 
taneously,  the  maternal  mortality  was  12-5  per  cent,  and  the  foetal 
mortality  37-5  per  cent. 

The  Rachitic  Triradiate  Pelvis. — -The  rachitic  triradiate 
or  pseudo-osteo-malacic  pelvis  very  closely  resembles  the  osteo- 
malacic pelvis,  and  is  the  result  of  very  similar  conditions.  It 
is  caused  by  a  severe  attack  of  rickets  occurring  at  some  period 
after  the  child  has  commenced  to  walk,  and  when  the  pressure 
of  the  femora  is  enabled  to  exert  its  full  influence  in  producing 
distortion.  The  more  advanced  degrees  of  deformity  are  pro- 
duced, as  in  true  osteo-malacia,  by  pressure  upon  the  outlet 
during  the  later  stages  of  the  disease,  when  confinement  to  bed 
becomes  necessary.  As  recovery  takes  place,  the  bones  rapidly 
harden  and  render  permanent  the  triradiate  appearance. 

Symptoms. — The  rachitic  triradiate  pelvis  usually  offers  a  com- 
plete obstruction  to  the  expulsion  of  the  foetus,  as  the  degree  of 
the  deformity  of  the  pelvis  is  as  great  as  in  osteo-malacia,  while, 
as  the  pelvic  bones  are  rigid,  they  cannot  be  forced  apart  by 
the  descending  head,  as  in  the  latter  condition. 

Diagnosis. — The  deformity  can  be  distinguished  in  the  adult 
from  true  osteo-malacia  by  the  history  and  presence  of  other 
rickety  signs,  and  by  the  fact  that  the  bones,  instead  of  being  soft 
and  pliable,  are  hard  and  irregular.  The  fossae  ilii  are  also  smaller 
than  normal ;  the  groove  on  the  iliac  bone  is  never  present,  and 
the  anterior  superior  iliac  spines,  instead  of  being  approximated, 
are  widely  separated  from  one  another,  as  in  other  varieties  of 
rachitic  deformity. 

Treatment.  —  Caesar ean  section  will  be  necessary  in  almost 
every  case,  if  the  foetus  is  to  be  saved.  The  only  alternative  is 
craniotomy. 

The  Spondylolisthetic  Pelvis. 

A  spondylolisthetic  pelvis  (o-7roV(k>Aos,  a  vertebra  ;  o  A  terpens,  a 
slipping)  is  one  which  is  deformed  by  the  detachment  of  the  last 
lumbar  vertebra  from  the  sacrum,  and  the  consequent  gliding 
forwards  of  the  lumbar  vertebral  column  under  the  influence  of 
the  body-weight  in  such  a  manner  as  to  overhang  the  pelvic  brim 
(Kilian*).  In  this  way,  another  form  of  pelvis  obtecta  is  produced, 
and  one  which  closely  resembles  that  found  in  certain  cases  of 
low  spinal  kyphosis  associated  with  caries  of  the  bodies  of  the 
vertebrae.  The  condition  with  which  we  are  now  dealing,  in 
which  the  vertebral  column  has  slipped  from  the  sacrum  owing 
to  defective  inter-articular  processes,  is  known  as  spondylolis- 
thesis, while  the  condition  to  which  we  have  already  referred,  in 
which  the  vertebral  column  slips  down  owing  to  caries  of  the 
vertebral  bodies,  is  known  as  spondylizema  (v.  Fig.  325). 

*   '  De  spondylolisthesis  Bonn,  1853. 


THE  SPONDYLOLISTHETIC  PELVIS  785 

Frequency. — This  is  one  of  the  rarest  forms  of  contracted  pelvis. 
At  the  time  at  which  Spiegelberg  wrote,  only  twelve  examples  of 
it  were  known  to  have  occurred. 

Characteristics. — The  deformity  in  this  class  of  pelvis  is  pro- 
duced by  a  slipping  downwards  and  forwards  of  the  body  of  the 
fifth  lumbar  vertebra  on  to  the  upper  part  of  the  anterior  aspect 
of  the  sacrum.  The  vertebral  body  in  its  descent,  which  always 
occurs  gradually,  carries  the  bodies  of  the  remaining  vertebrae 
along  with  it,  so  that  a  marked  lumbar  lordosis  is  produced  and 
the  height  of  the  individual  is  considerably  diminished.  After  a 
time,  the  fifth  lumbar  vertebra  becomes  fixed  in  its  new  position, 
with  its  lower  aspect  ankylosed  to  the  anterior  aspect  of  the  first 
sacral  vertebra.  This  variety  of  pelvis  is  very  rarely  met  with  in 
an  advanced  form,  but  minor  degrees  of  displacement  are  com- 
paratively common. 

The  predisposing  causes  of  the  downward  displacement  are  not 
quite  similar  in  all  cases.  The  condition  is  not  found  in  the 
foetus,  and  the  exciting  cause  after  birth  is  the  downward  pressure 
of  the  body-weight.  In  order  that  this  force  may  produce  such 
an  effect  there  must,  however,  be  some  alteration  of  the  structure 
or  attachments  of  the  fifth  lumbar  vertebra.  The  latter  is 
normally  anchored  securely  in  its  place  by  the  attachment  of  its 
neural  arch  to  the  laminae  of  the  first  sacral  vertebra  by  means 
of  the  posterior  ligaments,  and  by  the  apposition  of  its  inferior 
articular  facets  with  the  superior  articular  facets  of  the  sacrum. 
On  examining  the  body  of  this  vertebra  in  a  spondylolisthetic 
pelvis,  no  changes  further  than  what  can  be  referred  to  pressure 
atrophy  can  be  detected  in  the  majority  of  cases,  and  the  same 
remark  applies  to  the  body  of  the  first  sacral  vertebra.  It  is 
found,  however,  that  while  the  body  in  its  descent  has  carried  its 
superior  articular  processes  along  with  it,  the  inferior  articular 
processes  have  remained  fixed  in  their  normal  position,  so  that  a 
condition  of  great  antero-posterior  elongation  of  the  lower  part  of 
the  spinal  canal  has  been  produced.  It  may  be  stated,  in  passing, 
that  this  elongation  prevents  pressure  on  the  descending  trunks 
of  the  sacral  nerves.  Owing  to  the  above  fact,  it  seems  clear 
that  the  primary  cause  of  the  deformity  must  be  some  failure  of 
bony  union  between  the  laminae  and  inferior  articular  processes 
posteriorly,  and  the  body  of  the  vertebra  together  with  the 
superior  facets  and  a  portion  of  the  pedicles  anteriorly.  Such 
a  want  of  union  would  allow  the  body  to  be  displaced  slowly 
downwards  by  weakening  its  posterior  attachments,  and,  after  it 
had  come  to  rest,  union  could  readily  take  place  by  an  extension 
of  the  ossific  centres  of  the  body  and  neural  arch.*  In  many 
cases,  there  is  a  history  of  a  fall,  or  of  some  variety  of  injury, 
which     has    probably    caused    the    separation    by    producing    a 

*  In  this  connection,  it  is  interesting  to  note  that  some  observers  state  that 
the  neural  arch  of  the  fifth  lumbar  vertebra  is  always  ossified  by  two  centres 
on  each  side. 

50 


786 


THE  PATHOLOGY  OF  LABOUR 


fracture,  and  which  may  have  still  further  predisposed  to  the 
displacement  by  partially  dislocating  the  last  lumbar  vertebra 
forwards.  In  others,  there  is  a  history  or  signs  of  old  inflamma- 
tion. While,  in  a  few,  the  separation  must  be  referred  solely  to 
a  congenital  failure  of  development. 

The  effects  upon  the  pelvis  are  to  produce  great  shortening  of 
the  antero-posterior  diameter  at  the  brim,  owing  to  the  presence 
of  a  marked  anterior  lumbar  curvature,  which  causes  the  lumbar 
vertebrae  to  overhang  the  pelvic  inlet  (pelvis  obtecta).  This 
curvature  causes  the  centre  of  gravity  of  the  body  to  be  dis- 
placed forwards,  and  in  compensation  for  this  the  obliquity  of  the 
pelvis  is  much  diminished,  so  that  the  symphysis  pubis  assumes 


Fig.  332. — The  Spondylolisthetic  Pelvis. 


an  almost  vertical  position  and  its  upper  border  comes  to  lie 
opposite  the  third  or  second  lumbar  vertebra,  according  to  the 
degree  of  displacement.  The  pressure  backwards  upon  the  upper 
part  of  the  sacrum  effects  a  rotation  of  this  bone  upon  its  trans- 
verse axis.  The  promontory  moves  backwards,  causing  a  wide . 
separation  of  the  posterior  extremities  of  the  iliac  bones,  and  the 
apex  in  consequence  moves  forwards  and  upwards  into  the  pelvis. 
The  strain  thrown  upon  the  sacro-sciatic  ligaments  by  this  rotation 
draws  the  tubera  ischii  inwards,  and  produces  a  narrowing  of  the 
transverse  diameter  at  the  outlet,  which  is  in  contrast  with  the 
rather  wide  transverse  diameter  of  the  brim. 

Symptoms. — Ih  almost  all  recorded   cases,  the  degree  of  con- 


PELVIS  DEFORMED  BY  TUMOURS,  ETC.  787 

traction  present  was  so  great  that  the  passage  of  the  fcetus  was 
impossible. 

Diagnosis. — The  diagnosis  of  spondylolisthesis  is  chiefly  based 
upon  the  great  depression  of  the  lumbar  region,  this  being  in 
striking  contrast  to  the  upper  end  of  the  sacrum,  which  projects 
well  backwards  (Spiegelberg).  Further,  the  inclination  of  the 
pelvis  is  diminished,  and  the  sacral  and  gluteal  regions  are  broad, 
high,  and  steep.  The  posterior  and  anterior  superior  spines  are 
prominent,  and  the  distance  between  the  latter  is  increased. 

Treatment. — Csesarean  section  is  usually  required  if  the  foetus  is 
to  be  saved.  If  the  contraction  is  not  too  great,  the  induction  of 
premature  labour  may  sometimes  enable  the  fcetus  to  be  delivered 
per  vaginam. 

Pelvis    deformed    by    Tumours,    Fractures,    and 
Dislocations. 

The  most  common  tumour,  that  arises  from  the  pelvic  walls, 
is  an  enchondroma.     This  grows  most  frequently  from  the  upper 


Fig.  333. — The  Spondylolisthetic  Pelvis. 

Sagittal  section.     (Outline  of  normal  pelvis  in  black,  of  contracted 
pelvis  in  red.) 

part  of  the  anterior  aspect  of  the  sacrum,  or  from  some  other  part 
where  cartilage  is  found — as,  in  the  neighbourhood  of  the  sacro- 
iliac joint,  the  acetabulum,  or  the  back  of  the  symphysis  pubis. 
These  tumours  usually  become  ossified,  and  sometimes  form 
large  masses,  which  may  almost  completely  fill  the  pelvic  cavity. 
Exostoses  may  develop  as  a  result  of  inflammation,  or  of  ossifica- 
tion of  the  attachment  of  tendons  and  fasciae,  and  are  often  found 
in  the  anterior  part  of  the  ilio-pectineal  line,  where  a  pointed 
projection  inwards  may  be  found  on  one  or  other  side,  and  may 
attain  a  size  large  enough  to  cause  laceration  of  the  uterus. 
Such    a   projection    is    frequently  the    result    of  rickets,  and    is 

50—2 


788  THE  PATHOLOGY  OF  LABOUR 

especially  dangerous  when  it  occurs  in  association  with  rachitic 
contraction.  In  rickets  also,  the  retro-pubic  eminence  is  often 
markedly  accentuated,  and  by  introducing  an  obstacle  to  the 
descent  of  the  head  may  cause  a  posterior  parietal  presentation. 
Obstruction  may  also  be  caused  by  osteo-sarcomata,  fibromata, 
or  carcinomata.  A  rare  form  of  obstruction  is  that  in  which 
lymphatic  growths,  the  result  of  lymphatic  leukaemia,  encroach 
upon  the  pelvic  cavity  from  each  side.  As,  however,  leukaemia 
in  its  advanced  stages  usually  precludes  pregnancy,  it  is  unlikely 
that  such  growths  are  of  practical  obstetrical  importance. 

Obstruction  from  fracture  is  comparatively  rare,  and  may  arise 
either  from  the  primary  displacement  of  the  bone,  or  from  an 
overgrowth  of  callus,  which  has  failed  to  be  absorbed.  The 
deformity  thus  produced  will  obviously  depend  upon  the  situation 


Fig.  334. — Pelvis  Narrowed  by  Osteoid  Tumour  Springing 
from  the  Sacrum. 

and  extent  of  the  lesion.  Most  commonly  it  is  unilateral,  and 
consists  of  a  depression  of  the  anterior  part  of  the  pelvic  ring. 
Fracture  of  the  sacrum  or  coccyx,  or  dislocation  of  the  coccyx 
forward,  with  subsequent  ankylosis,  may  cause  narrowing  of  the 
conjugate  diameter  of  the  outlet.  A  similar  effect  may  be  pro- 
duced by  osseous  union  of  the  various  portions  of  the  coccyx  to 
one  another,  and  of  the  first  coccygeal  vertebra  to  the  sacrum. 
In  these  cases,  fracture  at  the  joint  must  occur  during  parturi- 
tion, either  by  natural  or  artificial  means,  to  allow  the  passage 
of  the  head. 

Symptoms. — The  symptoms  to  which  these  conditions  give  rise 
depend  on  the  exact  nature  of  the  pathological  condition  present, 
and  upon  the  degree  to  which  the  obstruction  encroaches  upon 
the  pelvic  diameters.  They  consist,  speaking  generally,  of  high 
situation    of    the    presenting   part,    the    occurrence    of    malpre- 


PELVIS  DEFORMED  BY  TUMOURS,  ETC.  789 

sentations,  and  a  varying  degree  of  obstruction  to  the  passage 
of  the  foetus.  Large  tumours,  which  prevent  the  descent  of  the 
presenting  part,  are  not  so  dangerous  as  small  exostoses.  The 
former  condition  is  recognised  at  once,  whilst  the  latter  may 
easily  escape  detection,  and  may  cause  rupture  of  the  uterus  by 
attrition  during  delivery  or  the  formation  of  fistulae. 

Diagnosis. — The  diagnosis  of  large  outgrowths  is  easily  made 
by  abdominal  palpation  or  vaginal  examination.  Small  exostoses 
can  only  be  recognised  by  a  careful  vaginal  examination,  and 
even  then  it  may  be  impossible  to  detect  them.  Whenever  the 
presenting    part  is  arrested    in  the   brim  or   in   the  cavity,  the 


Fig.  335. — The  Split  Pelvis. 

back  of  the  symphysis,  and  the  walls  of  the  pelvis  generally, 
should  be  examined  carefully  for  the  presence  of  such  growths, 
and  the  condition  of  the  sacro-coccygeal  articulation  be  ascertained. 
The  latter  is  done  by  grasping  the  coccyx  between  the  index- 
finger  in  the  vagina  and  the  thumb  externally  in  the  cleft  of  the 
nates.  Normally,  a  certain  degree  of  mobility  is  present,  but  if 
there  is  ankylosis  of  the  joint,  the  sacrum  and  the  coccyx  con- 
stitute a  single  bone,  and  all  mobility  is  lost.  If  the  coccyx  has 
been  previously  dislocated,  and  has  become  ankylosed  in  a  wrong 
position,  it  will  form  a  small  projection,  sticking  out  in  whatever 
direction  it  was  previously  displaced. 

Treatment. — The  treatment  to  be  adopted  depends  upon  the 
situation  of  the  growth,  fracture,  or  dislocation,  and  upon  its 
effect  upon  the  pelvic  diameters.     In  the  case  of  tumours  of  the 


790  THE  PATHOLOGY  OF  LABOUR 

soft  structures  of  the  pelvis,  Caesarean  section  is  usually  indicated, 
as  it  is  inadvisable,  in  consequence  of  the  danger  of  setting  up 
necrotic  changes,  to  subject  them  to  the  compression  that  would 
occur  if  a  fcetus  was  dragged  forcibly  past  them. 

Split  Pelvis. 

The  split  pelvis  is  almost  invariably  associated  with  ectopia 
vesicas,  and,  since  in  most  of  these  patients  the  generative  organs 
are  imperfectly  developed,  the  condition  is  very  seldom  met  with 
in  parturient  women.  Even  when  patients  the  subject  of  this 
malformation  do  become  pregnant,  little  or  no  difficulty  is 
experienced  during  labour,  in  consequence  of  the  absence  of  any 


Fig.  336. — The  Split  Pelvis. 

Outline  of  brim.      (Outline  of  normal  pelvis  in  black,  of  contracted 
pelvis  in  red.) 

resistance  in  front.  The  pubic  bones  are  not  in  contact  anteriorly, 
but  are  separated  by  an  interval  of  from  seven  to  eleven  centi- 
metres (Winckel),  which  is  filled  in  either  by  a  fibrous  band 
stretching  between  the  opposed  surfaces,  or  else  by  the  soft 
tissues  of  the  perinaeum.  The  sacrum  is  longer  than  normal, 
and  is  narrow,  and  it  is  displaced  forwards  into  the  pelvis,  lying 
deeply  between  the  iliac  bones,  to  which  it  is  attached  in  some 
cases  by  an  osseous  union.  The  conjugate  diameter  is  diminished 
in  length,  and  the  transverse,  though  often  actually  diminished,  is 
relatively  increased  by  the  outward  displacement  of  the  inno- 
minate bones.  On  the  whole,  the  pelvis  closely  resembles  the 
flattened  rachitic  form. 


CHAPTER  V 
ANOMALIES  OF  THE  GENITAL  ORGANS 

Tumours  of  the  Genital  Organs — Of  the  Uterus,  Fibro-myoma,  Cancer— Of 
the  Ovaries — Of  the  Vagina  and  Vulva.  Stenosis  and  Atresia  of  the 
Genital  Passages — Of  the  Cervix — Of  the  Vagina  and  Vulva. 

When  discussing,  in  a  former  chapter,*  the  effect  of  anomalies 
of  the  genital  organs  upon  pregnancy,  we  in  some  instances  also 
referred  to  their  effect  upon  labour,  because  it  was  found  difficult 
to  disassociate  the  two.  Accordingly,  we  need  not  here  again 
refer  to  the  effect  of  displacements  or  congenital  malformations  of 
the  uterus  upon  labour,  and  so  we  shall  only  deal  with  such  other 
anomalies  as  may  affect  the  course  of  labour.  These  fall  into  two 
groups : — 

I.  Tumours  of  the  genital  organs. 

II.  Stenosis  and  atresia  of  the  genital  passages. 

TUMOURS  OF  THE  GENITAL  PASSAGES. 

Tumours  of  the  genital  passages  affecting  the  course  of  labour 
may  spring  from  the  uterus,  the  ovaries,  the  vagina  and  the  vulva. 

Tumours  of  the  Uterus. 

The  principal  tumours,  which  may  be  met  with  in  the  uterus 
during  labour,  are  fibro-myomata  and  cancer.  These  must  be 
discussed  separately. 

Fibro-myoma  of  the  Uterus. — Fibro-myomata  are  perhaps 
the  most  common  form  of  tumour  met  with  as  a  complication  of 
pregnancy  or  labour.  As  has  been  already  pointed  out,  they 
rarely  affect  the  course  of  pregnancy,  though  sometimes  they  may 
cause  abortion.  They  are,  however,  not  uncommon  causes  of 
dystocia. 

Effect  on  Labour, — Myomata  may  affect  the  course  of  labour  in 

*  Vide  Part  VI.,  Chap.  IV.,  p.  552. 
791 


792 


THE  PATHOLOGY  OF  LABOUR 


one  of  three  ways  : — By  interfering  with  the  contractions  of  the 
uterus  either  prior  to,  during,  or  subsequent  to,  the  expulsion  of 
the  foetus  ;  by  offering  an  obstacle  to  the  descent  of  the  foetus  ;  or 
by  causing  a  malpresentation. 

It  is  extremely  difficult,  and  sometimes  quite  impossible,  to 
forecast  their  exact  effect  in  any  given  case.  In  attempting 
to  arrive  at  an  opinion,  three  factors  must  be  taken  into  con- 
sideration : — The  size  of  the  myoma  ;  its  position  as  regards  the 
uterus  :  and  its  position  as  regards  the  pelvic  cavity. 

The  size  of  the  myoma  is  an  all-important  factor.  These  tumours 
may  vary  in  size  from  that  of  a  hazel-nut  to  that  of  a  pumpkin, 

F- 


Fig.  337. — A  Myomatous  Uterus  which  is  Three  Months  Pregnant. 

F,  Myoma  of  fundus  ;  L,  myoma  of  lower  segment ;  O,  site  of  ovum  ; 
C,  cervix.     (Bumm.) 

and  whereas  tiny  myomata  will  give  rise  to  little  or  no  trouble, 
no  matter  where  they  are  situated,  and  medium-sized  myomata 
may  not  give  rise  to  trouble  unless  their  position  is  particularly 
unfavourable,  large  myomata  will  as  a  rule  affect  the  course  of 
labour  prejudicially  and  irrespective  of  their  position.  Very  small 
myomata,  if  numerous  and  interstitial,  may  interfere  with  the 
contraction  and  retraction  of  the  uterine  muscle,  and  so  cause 
delayed  labour  and  post-partum  haemorrhage,  particularly  if  they 
are  situated  in  the  neighbourhood  of  the  placental  site.  Medium- 
sized  and  large  myomata  may  bring  about  malpresentations  or 
offer  a  bar  to  the  descent  of  the  presenting  part. 

The  exact  situation  of  the  myoma  in  the  uterus  is  also  a  matter 
of  considerable  importance.     Fundal  myomata  may  give  rise  to 


FIBRO-MYOMA   OF  THE   UTERUS 


793 


weakened  and  irregular  contractions,  and  so  cause  delayed  labour 
and  post-partum  haemorrhage.  They  are  particularly  dangerous 
if  situated  in  the  neighbourhood  of  the  placental  site.  Myomata 
situated  in  front  of  the  presenting  part  may  offer  an  obstacle  to 
the  descent  of  the  part,  but  such  a  result  is  by  no  means  the  rule. 
It  not  infrequently  happens  that  a  myoma,  which  at  the  com- 
mencement of  labour  occupied  a  position  that  would  seem  to 
effectually  bar  the  descent  of  the  foetus,  is  drawn  up,  as  labour 


Fig.  338. — The  Myoma  shown  in  Fig.  337  at  Full  Term. 

F,  Myoma  at  the  fundus ;   L,  myoma  in  lower  segment  blocking  the  pelvic 
brim  ;   H,  head  of  fcetus  ;  C,  cervix.     (Bumm.) 

advances,  by  the  retraction  of  the  upper  uterine  segment  or  the 
cervix  (v.  Figs.  337-339).  Pedunculated  myomata  springing  from 
the  uterine  body  or  the  cervix,  and  which  protrude  into  the  vagina, 
will  not  be  drawn  up  in  this  manner,  and  if  of  sufficient  size  will 
almost  certainly  prevent  or  retard  the  descent  of  the  presenting 
part. 

A  myoma  springing  from  the  lower  uterine  segment  or  cervix 
may  be  freely  movable,  or  may  be  impacted  in  the  pelvic  cavity. 


794  THE  PATHOLOGY  OF  LABOUR 

If  it  is  movable,  it  is  frequently  possible  to  push  it  upwards 
above  the  presenting  part,  or  it  may  slip  above  it  as  labour 
proceeds,  as  has  been  just  described.  If  it  is  impacted,  it  is 
usually  impossible  to  push  it  upwards,  but  here  again,  unless  the 
impaction  is  very  firm,  the  retraction  of  the  uterus  may  draw  it 
upwards. 

Diagnosis. — The  existence  of  myomata  that  are  situated  above 
the  pelvic  brim  will  be  most  easily  ascertained  by  abdominal 
palpation.  They  may  be  found  as  single  or  multiple  nodules  of 
varying  size,  or  as  one  or  two  larger  masses.  When  they  are 
subserous,  there  is  usually  no  difficulty  in  recognising  their 
presence.  When  they  are  interstitial  or  submucous,  they  are 
often  mistaken  for  foetal  parts — small  myomata  counterfeiting  a 
foetal  elbow,  knee,  or  heel,  and  large  myomata  a  head  or  breech. 
In  such  cases,  their  presence  is  frequently  not  detected  until  the 
third  stage  of  labour.  A  diagnosis  is  made  by  noting  the  fact 
that,  while  a  foetal  part  can  be  moved  about  inside  the  uterus,  a 
myoma  in  the  uterine  wall  moves  with  the  uterus  and  possesses 
no  separate  range  of  motion.  Myomata  projecting  into  the  uterine 
cavity  impart  a  sense  of  increased  resistance  when  the  uterine 
wall  is  depressed  by  the  fingers,  and  render  it  difficult  or  im- 
possible to  palpate  the  subjacent  foetal  parts.  Pedunculated 
myomata,  attached  to  the  surface  of  the  uterus,  are  felt  as 
globular  masses  possessing  a  range  of  motion  in  proportion  to 
the  length  of  their  pedicle.  They  simulate  ovarian  tumours,  from 
which  it  is  difficult  to  distinguish  them  by  abdominal  palpation 
alone. 

The  existence  of  myomata  in  the  pelvic  cavity  may  be  suspected 
when  we  find  the  presenting  part  pushed  upwards  out  of  the 
pelvic  brim.  Their  presence  is  confirmed  by  a  vaginal  examina- 
tion, and,  at  the  same  time,  their  exact  relation  to  the  uterus  is 
ascertained.  In  some  cases,  it  maybe  necessary  to  administer  an 
anaesthetic  in  order  to  make  an  exact  diagnosis.  If  there  still  is 
any  doubt,  the  hand  should  be  passed  into  the  vagina,  and  the 
lower  segment  of  the  uterus  carefully  examined  with  one  or  more 
fingers  in  the  uterine  cavity,  if  the  uterine  orifice  is  sufficiently 
dilated  to  allow  the  finger  to  be  introduced.  In  the  case  of  a 
pedunculated  tumour  in  Douglas'  pouch,  the  differential  diagnosis 
between  a  myoma  and  a  solid  ovarian  tumour  may  be  difficult. 
However,  if  the  tumour  cannot  be  pushed  upwards  out  of  the 
pelvis,  it  must  be  removed  whether  it  is  uterine  or  ovarian,  and 
its  nature  will  be  then  discovered. 

Treatment. — The  treatment  of  myomata  during  labour  is  a 
difficult  matter  to  describe  shortly  in  a  text-book.  At  present, 
authorities  are  by  no  means  agreed  as  to  the  best  treatment  to 
adopt,  and  moreover  each  case  presents  so  many  features  that 
are  peculiar  to  it,  that  the  question  of  treatment  is  a  most  complex 
one.  The  various  procedures  which  may  be  adopted  are  as 
follows  : — 


FIBRO-MYOMA   OF  THE  UTERUS 


795 


(i)  The  Myoma  may  be  pushed  out  of  the  Pelvis. — This  pro- 
cedure should  always  be  attempted,  before  resorting  to  more 
radical  measures,  when  a  myoma  is  found  lying  below  the  pre- 
senting part.  If  the  myoma  is  not  impacted  in  the  pelvis,  it 
can  frequently  be  pushed  upwards,  but  the  administration  of  an 
anaesthetic  is  usually  necessary.  If  it  does  not  slip  up  at  the  first 
attempt,  we  should  wait  for  a  little — an  hour  or  two — according 
to  the  stage  of  labour,  and  then  try   again.     If  we   succeed    in 


Fig. 


339. — The  Myoma  shown  in  Figs.   337, 
Dilatation. 


during  the  Period  of 


F,  Myoma  of  fundus  ;  L,  myoma  of  lower  segment  which  has  been  drawn 
upwards  at  the  pelvic  brim  during  the  dilatation  of  the  cervix.     (Bumm.) 


pushing  the  tumour  above  the  presenting  part,  and  the  latter 
comes  down  into  the  pelvis,  the  expulsion  of  the  foetus  may  then 
be  left  to  the  natural  efforts,  or  the  forceps  may  be  applied. 

(2)  Expectant  Treatment  may  be  adopted. — By  expectant 
treatment  we  mean  that  the  delivery  of  the  foetus  is  left  to  the 
natural  efforts  until  the  condition  of  the  patient  calls  for  the 
termination  of  labour.  Such  a  course  can  usually  be  adopted 
in  cases  in  which  the  myoma  does  not  interfere  with  the  descent 


796 


THE  PATHOLOGY  OF  LABOUR 


of  the  presenting  part,  and  also  in  those  cases  in  which  we 
have  reason  to  believe  that  the  myoma  will  be  drawn  upwards 
out  of  the  pelvis  as  labour  proceeds.  If,  however,  the  myoma 
remains  below  the  presenting  part,  a  more  radical  treatment  must 
be  adopted. 

(3)  The  Myoma  may  be  removed. — This  is  only  necessary 
when  the  myoma  lies  below  the  presenting  part,  and  is  either 
pedunculated  or  situated  in  or  quite  close  to  the  cervix.     If  the 


Fig.   340. — A  Large  Subserous  Myoma  Impacted  in  Douglas'   Pouch, 
and  Blocking  the  Genital  Canal. 

F,  Subserous  myoma  of  fundus  ;  I,  interstitial  myoma  ;    D,  subserous  myoma 
in  Douglas'  pouch.     (Bumm.) 


myoma  is  pedunculated  and  protruding  into  the  vagina,  it  should 
always  be  removed.  In  such  a  case,  it  can  be  twisted  away,  or 
excised  after  ligation  of  the  pedicle.  If  it  is  sessile  and  within 
reach,  it  may  be  enucleated,  unless  it  is  drawn  upwards  as  labour 
proceeds. 

(4)  Caesarean  Section  may  be    performed,  followed  or  not  by 


FIBRO-MYOMA  OF  THE  UTERUS  797 

Hysterectomy.  —  This  procedure  is  only  necessary  when  the 
myoma  is  so  situated,  and  of  such  a  size,  as  to  prevent  the 
descent  of  the  presenting  part,  and  when  it  can  neither  be  removed 
nor  pushed  upwards  out  of  the  way.  If  Cesarean  section  has  to 
be  performed,  the  uterus  should  be  removed  at  the  same  time, 
unless  the  condition  of  the  patient  or  the  circumstances  under 
which  the  operation  is  performed  render  it  inadvisable  to  do  so. 
In  some  cases,  as  when  a  pedunculated  subserous  myoma  is 
impacted  in  the  pelvis,  it  may  be  possible  to  draw  the  tumour 
upwards  and  to  remove  it  either  without  performing  Csesarean 
section  or  after  it  has  been  performed,  and  thus  to  save  the 
uterus. 

The  choice  of  the  mode  of  treatment  to  be  adopted  depends 
almost  entirely  upon  the  nature  of  the  case  and  the  previous 
experience  of  the  obstetrician.  In  some  cases,  the  procedure  to 
be  adopted  is  obvious.  The  size  and  situation  of  the  myoma  may 
be  such  as  to  preclude  all  possibility  of  delivery  through  the 
vagina,  or,  on  the  other  hand,  they  may  offer  no  bar  to  the  natural 
delivery  of  the  foetus.  In  the  former  case,  Caesarean  section,  with 
or  without  a  following  hysterectomy,  and  in  the  latter  case  the 
expectant  treatment,  are  clearly  indicated.  In  other  cases,  the 
correct  procedure  is  not  so  obvious,  and  in  such  the  most  rational 
course  to  adopt  is  to  be  ready  to  perform  hysterectomy  if  neces- 
sary, but  to  wait  as  long  as  possible  to  see  whether  the  natural 
efforts,  aided  by  upward  pressure  from  the  vagina,  may  not  succeed 
in  removing  the  obstruction.  We  must  not,  however,  wait  too 
long,  as  by  so  doing  we  are  running  the  risk  of  being  compelled 
to  perform  Cesarean  section  under  unfavourable  circumstances. 
It  may  be  stated,  as  a  general  rule,  that  myomata  situated  on  the 
anterior  or  anterolateral  wall  of  the  uterus  are  likely  to  be  drawn 
upwards  during  labour,  while  myomata  on  the  posterior  or  postero- 
lateral wall  are  unlikely  to  be  drawn  up,  as  they  tend  to  become 
more  and  more  firmly  impacted  in  the  hollow  of  the  sacrum  as 
the  presenting  part  descends.  The  mere  fact  that  the  foetus  can 
be  dragged  past  a  myoma  in  the  pelvis  is  not  always  a  reason  for 
so  delivering  it,  as  the  risk  of  a  myoma  becoming  necrotic  and 
sloughing  after  it  has  been  much  compressed  is  very  great,  and 
the  prognosis  in  such  a  case  is  distinctly  worse  than  if  Caesarean 
section  had  been  performed  at  the  proper  time. 

Prognosis. — The  presence  of  a  myoma  is  a  serious  complication 
of  labour.  As  we  have  seen,  it  may  offer  an  obstruction  to 
delivery  and  so  cause  rupture  of  the  uterus  ;  it  may  so  affect  the 
contractions  that  uterine  inertia  results,  and  retained  placenta 
and  post-partum  haemorrhage  occur ;  it  may  be  so  crushed  during 
delivery  that  it  subsequently  sloughs,  and  septic  or  saprophytic 
infection  follows.  However,  with  the  advances  in  our  knowledge 
of  aseptic  technique  and  in  the  practice  of  operative  obstetrics 
and  gynaecology,  the  mortality  met  with  in  labours  complicated 
by  myomata  is  by  no  means  so  high  as  it  was  in  former  years. 


798  THE  PATHOLOGY  OF  LABOUR 

According  to  the  results  collected  by  two  observers*  prior  to  1890, 
out  of  372  cases  of  myomata  complicating  labour,  there  were 
196  maternal  deaths,  a  percentage  mortality  of  about  47;  while 
in  264  of  these  cases,  there  was  a  fetal  mortality  of  174,  or 
66  per  cent.  If  these  figures  are  compared  with  those  collected 
by  Thumin,+  of  cases  in  which  Csesarean  section  or  some  form 
of  hysterectomy  was  performed,  and  which  were  operated  upon 
between  1885  and  1900,  we  can  see  how  great  is  the  improvement. 
This  writer  gives  the  statistics  of  208  cases  with  22  maternal 
deaths,  a  percentage  mortality  of  10-5.  All  these  were  cases  in 
which  a  major  operation  was  performed,  whereas  the  former 
statistics  included  many  cases  in  which  delivery  was  effected  by 
the  natural  passages. 

Cancer  of  the  Uterus. — Cancer  of  the  uterus  as  met  with 
during  labour  almost  invariably  affects  the  cervix.  It  is  a  rare 
condition,  as,  if  it  is  far  advanced,  it  usually  prevents  the 
occurrence  of  conception. 

Effect  upon  Labour. — The  principal  effects  of  cancer  of  the 
cervix  upon  labour  is  to  interfere  with  the  progress  of  dilatation 
of  the  cervix  and  to  give  rise  to  cervical  laceration  and  haemor- 
rhage, since  the  normal  elastic  and  muscular  fibres  of  the  cervix 
are  replaced  by  the  non-elastic  and  friable  malignant  growth. 
Septic  infection  of  the  uterine  cavity  may  also  occur,  in  cases 
where  parts  of  the  cervix  are  sloughing. 

Diagnosis. — The  diagnosis  of  malignant  disease  of  the  cervix  is 
readily  made  by  means  of  a  vaginal  examination,  or  by  direct 
inspection  of  the  cervix  through  a  speculum.  The  characteristics 
of  cervical  cancer  are  so  well  known  that  they  need  not  be 
here  referred  to.  If  the  entire  cervix  is  affected,  there  will  be 
little  or  no  dilatation,  but,  if  the  disease  is  in  an  early  stage, 
dilatation  may  proceed  as  usual. 

Treatment. — When  discussing  the  treatment  of  cancer  of  the 
uterus  during  pregnancy,  we  stated  that  immediate  hysterectomy 
should  be  performed  in  all  cases  in  which  there  was  any  hope  of 
the  complete  removal  of  the  growth,  and  that  only  those  cases 
should  be  allowed  to  go  to  full  term  in  which  it  was  hopeless  to 
endeavour  to  save  the  mother's  life.  In  labour,  the  same  remark 
as  regards  immediate  operation  holds  true.  Malignant  disease  of 
the  uterus  grows  and  disseminates  itself  far  more  rapidly  during 
pregnancy  or  the  puerperium  than  it  does  at  other  times,  due  in 
all  probability  to  the  increased  size  and  number  of  the  blood  and 
lymph  vessels.  The  treatment  to  adopt  depends  upon  the  extent 
of  the  disease  and  the  circumstances  under  which  we  see  the 
patient.     One  of  three  courses  may  be  adopted  :— 

(1)  The  foetus    may  be   delivered   through   the  vagina  either 

*  Nauss  and  Susserott,  Jahresb.  u.  d.  Fortsch.  a.  d.  Gebiete  der  Gebmtsh.,  etc., 
vol.  v.,  p.  175. 

•j-  Archiv  fur  Gyncik.,  vol.  lxiv.,  1901,  No.  3,  pp.  457-525. 


CANCER  OF  THE  UTERUS  799 

without  or  after  preliminary  perforation  and  embryotomy,  and 
hysterectomy  performed  as  soon  subsequently  as  possible.  This 
procedure  can  be  adopted  when  the  disease  is  not  so  far  advanced 
as  to  prevent  the  necessary  dilatation  of  the  cervix.  It  is  not, 
however,  always  the  most  suitable  course,  as  the  risk  of  sub- 
sequent septic  infection  from  the  cervix,  a  risk  which  is  increased 
by  the  crushing  the  tissues  undergo,  is  very  considerable.  It 
may,  however,  be  necessary,  if  the  condition  of  the  patient  or 
her  surroundings  prevent  us  from  undertaking  an  immediate 
hysterectomy.  If  it  is  adopted,  the  uterus  should  be  removed 
at  the  earliest  possible  date. 

(2)  The  foetus  may  be  delivered  as  before,  and  an  immediate 
vaginal  hysterectomy  performed.  If  the  patient  is  seen  under 
favourable  circumstances,  this  is  a  wise  procedure  to  adopt,  as 
it  offers  the  best  prospect  of  avoiding  infection  of  either  the 
peritoneal  cavity  or  the  genital  tract.  The  necessary  dilatation  of 
the  cervix  may  be  obtained  by  introducing  hydrostatic  dilators, 
or  by  deep  incision  of  the  cervix  as  recommended  by  Diihrssen. 
The  latter  procedure  is,  however,  open  to  the  objection  that  it 
may  favour  the  dissemination  of  the  growth,  and  is  perhaps  better 
avoided. 

(3)  The  foetus  may  be  delivered  by  Csesarean  section,  followed, 
or  not,  by  the  removal  of  the  uterus  by  the  abdominal  or  vaginal 
route.  Delivery  by  Caesarean  section  is  the  only  procedure  which 
can  be  adopted  in  cases  in  which  the  disease  is  far  advanced.  If 
there  is  a  prospect  of  being  able  to  remove  the  entire  growth,  the 
delivery  of  the  foetus  should  be  followed  by  an  abdominal  or 
vaginal  hysterectomy.  Abdominal  hysterectomy  is  the  easier 
operation  on  account  of  the  large  size  of  the  uterus.  Whichever 
operation  is  adopted,  as  much  as  possible  of  the  diseased  tissue 
should  be  first  destroyed  with  the  cautery  per  vaginam,  in  order 
to  minimise  the  risk  of  peritoneal  infection.  If  there  is  no 
prospect  of  the  complete  removal  of  the  growth,  there  is  no 
object  in  performing  hysterectomy,  as  it  will  not  give  any  relief. 
In  such  cases,  temporary  benefit  will  be  obtained  by  the  destruc- 
tion of  as  much  of  the  growth  as  possible  by  the  cautery  and 
the  application  of  a  strong  solution  of  chloride  of  zinc. 

Prognosis. — The  prognosis  of  cancer  of  the  cervix,  occurring 
during  pregnancy  or  the  puerperium,  is  worse  than  is  the  prog- 
nosis of  the  same  condition  at  other  times.  Hense*  has  collected 
the  results  of  cases,  occurring  during  pregnancy  or  the  puerperium, 
in  which  radical  operations  were  performed,  and  which  were  under 
observation  for  at  least  five  years,  or  until  death  occurred,  and  has 
compared  them  with  the  results  in  cases  operated  on  after  the 
menopause.  Out  of  122  cases  in  which  radical  operations  were 
performed  during  pregnancy  or  the  puerperium,  41  were  watched 
for  the  necessary  time.  Of  these,  31  patients  died  of  a  recurrence 
of  the  growth,  and  10  patients,  or  24  per  cent.,  remained  well  after 
*  Zeitsch.  fur  Geburts  unci  Gynak.,  Bd.  xlvi. ,  No.  i,  1901. 


Soo  THE  PATHOLOGY  OF  LABOUR 

five  years  had  elapsed.  These  results  contrast  markedly  with 
the  results,  collected  by  the  same  writer,  of  radical  operations 
performed  upon  patients  who  were  past  the  menopause.  In 
73  cases  in  which  a  -sufficient  history  was  obtained,  there  were 
36  recurrences,  and  37,  or  more  than  50  per  cent.,  permanent 
cures. 

Tumours  of  the  Ovaries. 

Ovarian  tumours  are  occasionally  met  with  as  complications 

labour.  They  may  be  situated  either  in  the  abdominal  cavity 
to  one  or  other  side  of  the  uterus,  or,  if  of  smaller  size,  may  lie  in 
Douglas'  pouch.  Ovarian  tumours  situated  in  the  abdomen  do 
not  tend  to  cause  any  serious  difficulties  during  labour,  unless 
they  are  of  very  large  size,  when  they  may  press  the  uterus  out 
of  the  axis  of  the  pelvic  brim,  or  may  interfere  with  the  con- 
tractions of  the  voluntary  muscles,  and  so  delay  labour.  Such 
tumours  are,  however,  usually  diagnosed  before  the  onset  of 
labour,  and  should  in  all  cases  be  removed  as  soon  as  they  are 
recognised.  Ovarian  tumours,  which  have  prolapsed  into  the 
pelvis,  are  much  more  serious,  as  they  prevent  the  descent  of  the 
foetal  head.     It  is  with  them  that  we  are  here  chiefly  concerned. 

Frequency. — The  presence  of  a  pelvic  ovarian  tumour  compli- 
cating labour  is  of  rare  occurrence.  According  to  Haultain,* 
it  is  said  to  occur  once  in  4,000  cases.  McKerron.t  in  an 
exhaustive  paper  on  the  subject,  was  able  to  collect  183  cases, 
and  to  these  he  subsequently  added  a  further  series  of  80  cases.} 

Effect  on  Labour. — The  effect  on  labour  of  the  presence  of  an 
ovarian  tumour  in  the  pelvis  depends  on  the  size  of  the  tumour 
and  on  its  nature— i.£.,  whether  it  is  cystic  or  solid.  A  very  small 
solid  tumour  or  a  slightly  larger  cystic  one  may  get  pushed  into 
the  hollow  of  the  sacrum,  and  so  may  neither  offer  any  obstacle 
to  the  birth  of  the  foetus,  nor  may  itself  be  injured  during  the 
latter  process.  This,  however,  must  be  a  very  uncommon 
occurrence,  and,  as  a  rule,  an  ovarian  tumour  will  offer  a  partial 
or  complete  obstacle  to  the  descent  of  the  foetus,  and,  if  the  latter 
is  forced  past  it,  may  be  severely  crushed  and  ruptured.  In  the 
former  event,  the  obstruction  to  the  passage  of  the  foetus  may 
result  in  the  rupture  of  the  uterus,  while,  in  the  latter,  necrotic 
and  suppurative  changes  may  take  place  in  the  tumour  during 
the  puerperium,  and  these  in  turn  may  give  rise  to  a  general  or 
local  septic  infection.  A  third,  and  much  rarer  termination,  is 
also  possible,  in  which  the  foetus  in  its  descent  drives  the  tumour 
downwards,  and  forces  it  through  the  floor  of  Douglas'  pouch 

*  '  Expulsion  of  Dermoid  Ovarian  Cyst  per  Vaginam  during  Labour,' 
Journal  of  Obstetrics  and  Gynecology,  April,  1902,  p.  384. 

t  Trans.  Obstet.  Soc.  Lond.  for  1897,  p.  334. 

I  '  Pregnancy  with  Ovarian  Tumour,'  by  R.  G.  McKerron,  M.B.  1903, 
Rebman. 


TREATMENT  OF  OVARIAN  TUMOUR 


801 


and  the  posterior  vaginal  wall,  or  in  a  few  cases  into  the  rectum. 
To  this  occurrence,  the  term  '  natural  ovariotomy  '  was  applied 
by  Playfair. 

Diagnosis. — The  diagnosis  of  the  presence  of  an  ovarian  tumour 
in  the  pelvis  cannot  in  all  cases  be  made  prior  to  opening  the 
abdomen.  If  a  cystic  tumour  is  found  in  Douglas'  pouch,  it  is 
almost  certainly  of  ovarian  origin,  and  it  may  be  sometimes 
possible  to  make  the  diagnosis  certain  by  determining  the  rela- 
tions of  the  tumour  to  the  uterus  and  pelvis.  The  diagnosis  of 
a  solid  tumour  is  more  difficult,  and  the  latter  can  seldom  be 
distinguished  from  a  myoma  prior  to  its  removal.  This,  how- 
ever, is  of  no  practical  importance,  as  in  each  case  the  treat- 
ment is  similar. 

Treatment.— A  case  in  which  a  pelvic  ovarian  tumour  compli- 
cates labour  may  be  treated  in  one  of  the  following  ways  : — 

(i)  Delivery  may  be  left  entirely  to  the  natural  efforts. 

(2)  The  tumour  may  be  pushed  upwards  into  the  abdomen, 
and  delivery  then  effected  artificially  or  left  to  the  natural  efforts. 

(3)  Delivery  may  be  effected  artificially,  without  reduction  or 
reposition  of  the  tumour. 

(4)  The  tumour,  if  cystic,  may  be  punctured  or  incised,  and 
delivery  then  effected  artificially  or  left  to  the  natural  efforts. 

(5)  Delivery  by  Caesarean  section,  followed  by  ovariotomy. 

(6)  Ovariotomy  by  the  abdominal  or  vaginal  route,  followed  by 
natural  or  artificial  delivery. 

Before  discussing  these  methods,  it  may  be  well  to  see  what 
have  been  their  respective  results  in  the  past,  as  gathered  from 
the  statistics  collected  by  McKerron,*  first  in  his  communication 
to  the  London  Obstetrical  Society,  and  secondly  in  his  monograph 
on  this  subject  : — 


Mode  of  Delivery. 

No.  OF 

Cases. 

Deaths. 

Percentage 
Mortality. 

ist 
Series. 

2nd 

Series. 

ist 

Series. 

2nd 

Series. 

| 

ist             2nd 

Series.        Series. 

By  natural  efforts  - 
Reposition 
Artificial    delivery 

without  reduction 

or  reposition 
Puncture  or  incision 
Caesarean  section    - 
Ventral  ovariotomy 
Vaginal  ovariotomy 

35 

4i 

49 

43 

10 

2 

3 

5 
21 

19 

T3 

12 

6 

4 

12 

7 

22 
8 
8 
0 
0 

0 
2 

4 

1 
1 
0 
0 

34 
17 

45 

18 

So 

0 

0 

0 

95 

21 
77 
8-3 

0 
0 

As  the  percentage  mortality  with  the  different  modes  of  treat- 
ment differs  considerably  in  the  two  series,  we  have  thought  it 

*  Op.  cit. 

5* 


802 


THE  PATHOLOGY  OF  LABOUR 


well  to  group  together  the  cases  from  both  series  which  occurred 
subsequent  to  1890.  The  number  and  result  of  these  cases  is 
shown  in  the  following  table  : — 


Mode  of  Delivery. 

No.  of  Cases. 

Deaths. 

Percentage 
Mortality. 

By  natural  efforts     - 
Reposition        ..--■- 
Artificial  delivery  without  re- 
duction or  reposition    - 
Puncture  or  incision 
Cassarean  section     - 
Ventral  ovariotomy 
Vaginal  ovariotomy 

2 
20 

18 

17 

14 

8 

7 

0 
2 

6 
0 

1 
0 
0 

0 
10 

33'3 
0 

7'i 

0 

0 

Total 

86 

9 

I0'4 

From  these  tables,  we  can  obtain  information  which  may  guide 
us  in  the  selection  of  the  most  suitable  treatment.  Delivery  by 
the  natural  efforts  alone  gave  disastrous  results  at  the  time  it 
was  adopted.  Since  1890,  it  has  been  practically  abandoned, 
though  two  successful  cases  are  recorded.  Artificial  delivery 
— i.e.,  delivery  by  forceps,  version  or  perforation — both  in  past 
and  recent  times  has  given  equally  bad  results,  and  must  be 
condemned  absolutely.  The  other  modes  of  treatment  may 
all  be  regarded  as  satisfactory,  but  the  statistics  of  immediate 
ovariotomy  are  considerably  the  best.  It  is  hardly  necessary  to 
emphasise  the  fact  that  in  all  cases  in  which  Caesarean  section 
is  performed  it  should  be  accompanied  by  ovariotomy.  Accord- 
ingly, we  may  take  into  account  four  modes  of  treatment : — ■ 
Reposition  ;  reduction  in  size,  followed  by  natural  or  artificial 
delivery  ;  Caesarean  section,  followed  by  ovariotomy  ;  and  ab- 
dominal or  vaginal  ovariotomy,  followed  by  natural  or  artificial 
delivery. 

(1)  Reposition. — The  reposition  of  the  tumour — that  is,  the 
pushing  it  upwards  out  of  the  pelvic  cavity — can  be  performed 
under  the  following  conditions : — The  presenting  part  must  not 
be  fixed ;  the  tumour  must  not  be  impacted  or  adherent ;  and 
the  pedicle  must  be  of  sufficient  length  to  allow  the  necessary 
change  in  position  of  the  tumour.  The  relatively  high  rate  of 
mortality,  which  has  attended  this  procedure,  is  due  chiefly  to  the 
subsequent  occurrence  of  septic  peritonitis  from  infection  of  the 
contents  of  the  tumour.  At  first  sight,  reposition  seems  a  simple 
and  safe  procedure,  but  the  danger  of  lacerating  the  tumour  or 
twisting  its  pedicle  during  reposition  is  considerable.  It  is  not 
the  treatment  of  election,  and  should  be  kept  for  those  cases  in 
which  circumstances  forbid  the  performance  of  a  major  operation. 
It  is  carried  out  by  placing  the  patient  in  the  knee-chest  position, 
and  then  pushing  the  tumour  upwards  with  the  fingers  in  the 


TREATMENT  OF  OVARIAN  TUMOUR 


803 


vagina  or  rectum,  as  the  case  may  be,  very  much  as  is  done  in 
the  reposition  of  an  incarcerated  retroverted  uterus.  The  ad- 
ministration of  an  anaesthetic  will  usually  be  required.  The 
tumour  must  be  removed  as  soon  as  possible  after  delivery. 

(2)  Reduction  in  Size. — A  cystic  tumour  may  be  reduced  in 
size  by  puncture  with  a  trochar  and  canula  through  the  pos- 
terior vaginal  wall,  or  its  contents  may  be  drained  off  by  making 
an  incision  into  it.     The  cause  of  the  high  mortality  in  the  past 


Fig.  341. — A  Large  Ovarian  Cyst  complicating  Pregnancy.  Part  of  the 
Cyst  is  Impacted. in  Douglas'  Pouch,  and  prevents  the  Descent 
of  the  Head. 

C,  Ovarian  cyst  ;  P,  posterior  lip  of  cervix  ;  A,  anterior  lip.     (Bumm. ) 


was  apparently  septic  infection,  and,  with  improved  modern 
technique,  seventeen  cases  have  been  recorded  in  recent  years 
without  a  death.  This  procedure  may  be  adopted  when  a  major 
operation  cannot  be  performed  and  attempts  at  reposition  have 
failed,  and  should  be  followed  by  an  ovariotomy  at  the  earliest 
possible  date.  It  may  also  be  adopted  when  the  tumour  cannot 
be  removed,  by  either  vaginal  or  abdominal  cceliotomy,  until  the 
uterus  has  been  emptied — that  is,  in  cases  in  which  the  alterna- 

51—2 


8o4  THE  PATHOLOGY  OF  LABOUR 

tive  would  be  to  perform  Caesarean  section  and  then  ovariotomy. 
In  such  cases,  by  puncturing  or  incising  the  tumour,  extracting 
the  fcetus,  and  then  performing  ovariotomy  by  whatever  route  is 
thought  best,  the  necessity  for  Cesarean  section  is  avoided. 
When  immediate  ovariotomy  cannot  be  performed,  and  the 
tumour  has  been  incised,  its  cavity  should  be  kept  plugged  with 
iodoform  gauze,  which  is  changed  daily.- 

(3)  Cassarean  Section.  - — ■  Caesarean  section  is  only  required 
in  cases  of  solid  tumours  which  cannot  be  removed  until  the 
uterus  has  been  emptied.  It  should  be  always  accompanied  by 
ovariotomy. 

(4)  Ventral  or  Vaginal  Ovariotomy.  —  Ventral  or  vaginal 
ovariotomy  constitutes  the  most  suitable  procedure  in  all  cases 
in  which  the  condition  of  the  patient  and  her  surroundings  do  not 
forbid  the  performance  of  a  major  operation.  The  vaginal  route 
is  preferable,  and  is  the  only  possible  route  in  cases  in  which 
the  presenting  part  is  fixed.  If  part  of  the  tumour  extends  into 
the  abdominal  cavity,  the  ventral  route  must  be  adopted. 

Prognosis. — The  figures  which  we  have  given  in  the  second 
table  above  show  a  death  rate  in  recent  years  of  less  than  10-5  per 
cent,  for  all  cases  of  ovarian  intra-pelvic  tumours.  These  results 
show  an  enormous  improvement  over  the  earlier  results,  as,  prior 
to  1876,  the  maternal  mortality  was  34^7  per  cent. 

Tumours  of  Vagina  and  Vulva. 

New  growths  met  with  in  the  vagina  may  spring  from  the 
vaginal  walls  or  from  the  uterus.  In  the  latter  case,  they  are 
usually  polypi  which  have  been  expelled  from  the  uterus,  or 
which  are  growing  from  the  cervix.  Their  treatment  has  been 
already  referred  to  when  discussing  myomata.  New  growths 
having  their  origin  in  the  vagina  are  extremely  rare,  and  need  not 
be  taken  into  account.  Cancer  of  the  vulva,  however,  is  occa- 
sionally met  with,  though  it  is  also  a  very  rare  condition. 
Tumours  other  than  new  growths  occasionally  occur.  The  most 
common  are  cedematous  swellings  of  the  labia,  vaginal  and  vulvar 
cysts,  and  haematomata. 

Effect  on  Labour. — Malignant  disease  of  the  vagina  or  vulva 
affects  labour  in  a  similar  manner  to  malignant  disease  of  the 
cervix — that  is  to  say,  it  tends  to  cause  narrowing  and  obliteration 
of  the  passage.  The  other  tumours  act  similarly,  but  as  they 
can  be  removed  they  are  not  important. 

Treatment. — Malignant  disease  of  the  vagina  or  vulva  is,  as 
a  rule,  both  an  actual  and  a  theoretical  bar  to  delivery  through 
the  natural  passages.  If  the  disease  is  at  all  advanced,  it  will 
prevent  the  necessary  dilatation  of  the  canal,  while  in  any  case — 
as  in  cervical  cancer — the  bruising  which  it  undergoes  during  the 
extraction  of  the  fcetus  favours  dissemination,  and,  at  the  same 
time,  by  causing  necrosis,  increases  the  danger  of  septic  infection. 


STENOSIS  AND  ATRESIA  OF  THE  CERVIX  805 

Accordingly,  in  almost  every  case  in  which  the  conditions  of  the 
patient  and  her  surroundings  are  favourable  to  the  performance 
of  a  major  operation,  Caesarean  section  constitutes  the  best  line 
of  treatment.  If  circumstances  forbid  its  performance,  then 
delivery  by  the  natural  passages  may  be  carried  out,  provided 
that  the  growth  is  not  so  extensive  as  to  render  the  passage  of 
even  a  mutilated  foetus  impossible.  When  the  growth  is  situated 
at  the  vulva,  additional  space  for  the  passage  of  the  foetus  may  be 
obtained  by  deep  incisions  of  the  perinaeum.  Such  a  procedure 
is,  however,  distinctly  inadvisable,  as  it  favours  dissemination 
and  septic  infection,  and  should  only  be  adopted  in  cases  in 
which  the  performance  of  Caesarean  section  is  impossible. 

The  treatment  of  the  other  forms  of  tumour  is  more  simple. 
CEdematous  swellings  of  the  vulva  rarely  cause  any  trouble.  If 
they  are  so  large  as  to  obstruct  delivery,  they  must  be  punctured, 
and  the  fluid  allowed  to  drain  away.  Puncture  should,  however, 
be  avoided  whenever  possible,  as  the  anaemic  condition  of  the 
parts  retards  the  healing  of  any  wounds  of  the  skin.  Punctured 
wounds  are,  however,  preferable  to  the  lacerated  wounds  caused 
by  rupture,  and  therefore  ought  always  to  be  made  if  there 
appears  to  be  any  danger  of  rupture. 

Vaginal  cysts  are  sometimes  met  with,  but  vulvar  cysts  con- 
nected with  Bartholin's  gland  or  its  duct  are  more  common.  If 
they  are  of  such  a  size  as  to  offer  an  obstruction  to  delivery,  they 
must  be  punctured  with  all  aseptic  precautions.  Subsequently, 
if  they  fill  again,  they  must  be  removed. 

The  treatment  of  haematomata  will  be  referred  to  later. :: 


STENOSIS  AND  ATRESIA  OF  THE  GENITAL 
PASSAGES 

Stenosis  and  Atresia  of  the  Cervix.  —  Stenosis  (arevos, 
narrow)  is  the  term  applied  to  the  narrowing  of  the  lumen  of  a 
canal,  while  atresia  means  an  imperforate  condition  (d,  negative; 
Terpaivto,  I  perforate).  All  cases  of  atresia,  as  met  with  in 
pregnancy  and  labour,  may  be  regarded  as  only  advanced  cases 
of  stenosis,  inasmuch  as  it  is  obvious  that  the  atresia  cannot  have 
existed  prior  to  conception.  Accordingly,  the  two  conditions  may 
be  discussed  together. 

^Etiology. — The  causes  of  stenosis  or  atresia  are  to  be  found  in 
any  condition  that  has  destroyed  or  altered  the  normal  tissues  of 
the  cervix.  These  causes  may  be  grouped  together  according 
as  they  are  due  to  the  effects  of  age,  to  inflammatory  changes, 
to  traumata,  and  to  new  growths.  In  elderly  primiparae,  there 
is  sometimes  an  increased  rigidity  of  the  fibres  round  the  os 
externum  or  of  the  entire  vaginal  portion,  due  probably  to  the 
diminution  in  the  number  of  elastic  fibres  consequent  on  com- 
*   Vide  Part  VII.,  Chap.  IX.,  p.  860. 


8o6  THE  PATHOLOGY  OF  LABOUR 

mencing  senile  atrophy  (Diihrssen).  Stenosis,  the  result  of 
inflammatory  changes,  must  be  of  very  rare  occurrence,  as  it  is 
doubtful  whether  the  common  simple  inflammations  of  the  cervix 
ever  give  rise  to  it.  It  may,  however,  occur  in  cases  of  extensive 
ulceration,  the  result  of  an  acute  septic  or  gonorrhceal  process,  or 
of  syphilis.  Stenosis,  the  result  of  trauma,  is,  on  the  other  hand, 
perhaps  the  commonest  form  met  with.  It  may  be  the  result  of 
extensive  lacerations  of  the  cervix  ;  of  badly  performed  or  too 
extensive  operations,  as  trachelorrhaphy  or  amputation  of  the 
cervix  ;  of  extensive  sloughing  of  the  cervix,  the  result  of  a  pro- 
longed labour,  or  of  the  too  extensive  use  of  caustics  ;  or  of  the 
friction  and  irritation  to  which  the  cervix  is  subjected  in  cases  of 
long-standing  prolapse  of  that  part.  The  effect  of  new  growths 
on  the  cervix  has  been  already  dealt  with,  and  we  have  seen  that 
malignant  disease  of  that  part  always  gives  rise  to  stenosis,  and 
when  it  has  become  extensive  even  to  atresia. 

Effect  on  Labour. — The  effect  of  atresia  or  stenosis  on  labour 
is  to  produce  a  condition  closely  resembling  that  which  has  been 
described  under  the  head  of  spasmodic  contraction  of  the  cervix, 
save  that  the  resulting  stricture  is  organic  instead  of  functional. 
In  atresia,  the  cervix  in  many  cases  will  not  dilate  until  a  new 
opening  has  been  made.  In  stenosis,  dilatation  is  delayed  or 
never  occurs,  according  to  the  degree  to  which  the  tissues  are 
altered.  Serious  consequences  may  result  from  this.  First,  and 
most  commonly,  the  contractions  are  not  strong  enough  to  over- 
come the  resistance  ;  they  die  away,  and  a  condition  of  uterine 
inertia  results.  Secondly,  the  contractions  may  force  the  foetus 
through  the  narrow  cervix  and  cause  extensive  lacerations,  leading 
to  the  occurrence  of  traumatic  post-partum  haemorrhage.  Thirdly, 
the  condition  of  the  cervix  may  prevent  the  passage  of  the  foetus, 
and,  the  contractions  continuing,  rupture  of  the  uterus  may  occur. 

Diagnosis. — The  diagnosis  of  stenosis  of  the  cervix  is  readily 
made  by  means  of  a  vaginal  examination,  after  labour  has  been 
in  progress  for  a  little  time.  The  cervix  is  found  to  be  but  little 
if  at  all  dilated,  and  in  part  or  altogether  preserves  the  shape  it 
possessed  prior  to  the  onset  of  labour.  The  cause  of  the  stenosis 
may  be  found  on  careful  examination  or  inspection.  In  atresia 
of  the  os  externum,  the  taking  up  of  the  cervix  may  proceed  as 
usual,  but,  on  examination,  the  smooth  and  thinned-out  tissues  of 
the  cervix  are  found  to  completely  cover  the  presenting  part,  and 
no  aperture  can  be  felt.  A  small  dimple,  or  thickening,  corre- 
sponding to  the  former  site  of  the  os  can  usually  be  detected.  If 
the  stenosis  or  atresia  affects  more  than  the  region  of  the  os 
externum,  the  affected  portion  of  the  cervix  will  be  felt  projecting 
from  the  lower  pole  of  the  uterus  as  a  mushroom-like  prominence 
of  a  thickness  varying  with  the  extent  of  cervix  affected. 

Treatment. — The  treatment  of  atresia  consists  in  re-constituting 
the  obliterated  portion  of  the  cervical  canal.  If  the  os  externum 
alone  is  obliterated,  due  to  simple  agglutination  of  the  edges, 


STENOSIS  OF  THE  VAGINA  AND  VULVA  807 

slight  pressure  with  the  tip  of  the  finger  or  with  the  point  of  a 
sound  may  suffice  to  re-open  it.  If  this  is  not  sufficient,  an 
incision  must  be  made  with  a  scalpel.  Once  the  canal  has  been 
re-opened,  rapid  dilatation  will  as  a  rule  occur.  In  cases  of 
stenosis  due  to  causes  other  than  malignant  disease,  dilatation 
may  be  hastened  by  hot  vaginal  douches,  and  hot  hip-baths.  If, 
however,  the  alterations  in  the  tissues  are  extensive,  the  cervix 
must  be  dilated  or  incised.  The  manner  in  which  these  pro- 
cedures are  carried  out  will  be  described  later.  As  a  general 
rule,  it  will  be  found  that  if  the  undilated  portion  of  cervix  is 
thin,  and  consists  only  of  the  tissues  in  the  neighbourhood  of  the 
external  os,  incision  is  preferable,  while  if  there  is  a  considerable 
thickness  of  undilated  cervix,  dilatation  is  preferable.  The  treat- 
ment of  stenosis  due  to  cancer  of  the  cervix  has  been  already 
described. 

Stenosis  of  the  Vagina  and  Vulva. — Stenosis  of  the  vagina 
or  vulva  may  occur  as  a  result  of  congenital  deformities,  previous 
extensive  ulceration,  or  malignant  disease.  In  some  cases,  it  may 
be  so  marked  that  the  canal  is  barely  patent. 

Effect  on  Labour. — The  effect  on  labour  is  identical  with  that  of 
stenosis  of  the  cervix,  i.e.,  obstructed  delivery  and  possibly  ex- 
tensive lacerations  of  the  stenosed  part  during  the  passage  of  the 
foetus. 

Diagnosis. — The  diagnosis  is  readily  made  by  a  vaginal  examina- 
tion, but  care  must  be  taken  to  prevent  mistaking  the  ring  of 
stenosed  tissue  for  the  edges  of  the  uterine  orifice.  If  the  possi- 
bility of  confusing  the  two  conditions  is  remembered,  the  mistake 
will  not  be  made. 

Treatment. — Stenosis  due  to  the  presence  of  cicatricial  bands  or 
congenital  septa  may  be  relieved  by  the  division  of  such  bands  or 
septa.  Slight  degrees  of  cicatricial  stenosis  may  be  relaxed  by 
hot  douches,  glycerine  plugs,  or  by  the  use  of  a  hydrostatic  dilator. 
In  more  marked  degrees,  it  may  be  necessary  to  make  several 
incisions  in  the  constricting  tissues.  These  incisions  are  made 
peripherally  round  the  stenosed  portion  of  the  vagina,  and  must 
be  sufficiently  deep  to  divide  the  cicatrices.  The  foetus  is  then 
extracted  with  the  forceps,  if  the  natural  efforts  are  not  sufficient 
to  expel  it.  If  the  incisions  subsequently  bleed,  they  must  be 
sutured,  or  the  uterus  and  vagina  must  be  tamponned  with 
iodoform  gauze.  If  the  stenosis  is  so  great  that  sufficient  room 
for  the  passage  of  the  foetus  cannot  be  obtained  by  incision, 
the  foetus — if  dead — may  be  perforated  and  extracted,  or,  if  the 
contraction  is  too  great  even  for  this  to  be  successful,  Caesarean 
section  must  be  performed.  If  the  stenosis  is  situated  at  the 
orifice  of  the  vagina,  sufficient  space  may  be  obtained  by  the 
performance  of  episiotomy  or  incision  of  the  perinaeum. 


CHAPTER  VI 

MULTIPLE    PREGNANCY 

Multiple  Pregnancy  —  Frequency — iEtiology — Superfoetation — Superfecunda- 
tion  —  Presentation  —  Sex  and  Development  —  Diagnosis  —  Course  of 
Labour  —  Management  —  Prognosis.  Interlocking  of  the  Infants  — 
Diagnosis — Treatment. 

MULTIPLE  PREGNANCY 

By  multiple  pregnancy,  is  meant  the  simultaneous  presence  of 
more  than  one  foetus  in  the  uterus.  The  greatest  number  of 
children  born  at  a  birth,  which  has  been  authentically  reported, 
is  six. 

Frequency. — Twin  pregnancies  are  of  comparatively  frequent 
occurrence,  but  the  exact  proportion  of  cases  in  which  they  occur 
varies  considerably  in  different  countries.  Thus  Churchill* 
found  amongst  285,219  labours  occurring  in  the  British  Isles, 
3,718  cases  of  twins,  or  a  proportion  of  1  in  76-5  ;  while, 
according  to  French  statistics  as  collected  by  Bertillon,  the  pro- 
portion in  France  is  1  in  101.  The  statistics  of  the  Rotunda 
Hospital  show  a  proportion  of  1  in  76-62. 

Triplets  are  of  very  much  rarer  occurrence.  In  Churchill's  list 
of  British  cases,  43  instances  of  triplets  are  recorded,  a  proportion 
of  1  in  6,000.  According  to  the  statistics  of  Dubois,  based  on 
484,550  labours  occurring  in  England,  France,  and  Germany,  the 
proportion  of  triplets  was  1  in  6,209.  The  statistics  of  the 
Rotunda  Hospital  show  a  proportion  of  1  in  5,000,  but  this  pro- 
portion is  considerably  in  excess  of  the  true  proportion  in  Ireland, 
as  the  tendency  of  such  patients  is  to  seek  the  aid  of  a  maternity 
hospital,  owing  to  the  size  of  the  uterus  or  some  concomitant 
pathological  condition. 

The  proportion  of  cases  in  which  quadruplets  occur  is  1  in 
371,126,  according  to  Veit.  Quintlets  are  of  too  rare  occurrence 
to  be  able  to  give  even  an  approximate  proportion.     So  far  as  we 

*  Op.  cit.,  p.  4S0. 


THE  /ETIOLOGY  OE  MULTIPLE  PREGNANCY  S09 

know,  at  least  two  authentic  cases  of  sexlets  have  been  recorded. 
The  first  case  was  recorded  by  Vassali  in  1888.  There  were 
four  boys  and  two  girls,  who  altogether  weighed  1,730  grammes 
(3  lb.  13  oz.),  the  largest  weighing  305  grammes  (10  oz.  12 
drams),  the  smallest  240  grammes  (8  oz.  7-5  drams). 

The  second  case  was  recorded  by  Kerr  and  Cookman,*  and 
occurred  at  Accra,  on  the  Gold  Coast,  in  a  negress.  Five  of  the 
children  were  boys,  the  sixth  a  girl.  Between  the  children,  there 
were  four  placentae.  The  girl  and  one  boy  had  a  placenta  each, 
while  the  remaining  four  children  were  attached  by  pairs  to  two 
placentae.  All  the  children  were  born  alive.  One  lived  two  days, 
four  lived  three  days,  and  one  lived  four  days.  It  is  stated  that 
the  patient  at  her  first  confinement  gave  birth  to  four  children,  at 
her  second  confinement  to  three  children,  at  her  third  to  three 
children,  and  at  her  fourth — that  to  which  we  refer — to  six 
children,  a  total  of  sixteen  children  at  four  confinements. 


Fig.  342. — A  Case  of  Sexlets.     (Kerr  and  Cookman,  from  a  photograph.) 

Aetiology. — Twin  pregnancy  may  result  in  one  of  three  ways : — 

(1)  Two  distinct  ova  may  be  fertilised.  These  ova  may  come 
from  separate  Graafian  follicles,  which  may  both  come  from  one 
ovary  or  one  from  each  ovary,  or  they  may  come  from  the  same 
Graafian  follicle.  Twins  derived  in  such  a  manner  will  be 
entirely  separate  from  one  another  and  have  separate  placentae, 
separate  amnions,  and  separate  chorions  (v.  Fig.  343). 

(2)  One  ovum  may  contain  two  yolk  sacs,  each  with  its  own 
nucleus.  Twins  derived  in  such  a  manner  will  have  a  common 
placenta  and  chorion,  and  separate  amnions  (v.  Fig.  344). 

(3)  A  single  germinal  area  may  divide  into  two  embryos.  In 
such  a  case  there  will  be  a  common  placenta,  chorion,  and 
amniotic  sac  (v.  Fig.  345). 

It  must  be  remembered  that  in  the  case  of  twins  derived  in  the 
first  manner,  the  placentae  may  lie  so  close  to  one  another  in  the 
uterus  that  their  edges  coalesce,  and  a  common  placenta  ap- 
parently result.  The  fact  that  there  are  two  chorions  will,  how- 
ever, render  the  nature  of  the  case  clear.  Also,  in  the  case  of 
twins  derived  in  the  second  .manner,  the  double  fold  of  amnion 

*  Medical  Press  and  Circular,  May  27,  1903,  p.  538. 


Sio 


THE  PATHOLOGY  OF  LABOUR 


which  intervenes  between  the  two  sacs  may  become  absorbed, 
and  the  twins  may  thus  lie  in  a  common  amniotic  sac.  This  is 
said  to  occur  in  about  twelve  per  cent,  of  such  cases  (Galabin), 
and  renders  it  practically  impossible  to  distinguish  them  from 
those  arising  in  the  third  manner.  Triplets  usually  arise  as  a 
result  of  twins  developing  from  one  ovum  and  a  single  embryo 
from  another,  and  quadruplets  are  probably  due  to  two  sets  of 
twins,  each  developed  from  a  single  ovum.  In  one  of  the  most 
recently  recorded  cases  of  quintlets — that  by  Sato*  of  Japan, 
the  first  and  the  second  foetus  were  apparently  developed  from 


Fig.  343. — Diagram  of  Bi-ovular  Twins. 
Note  the  separate  placentas,  chorions,  and  amnions. 


one  ovum,  the  third  and  the  fourth  from  another,  and  the  fifth 
from  a  third. 

The  actual  causes  which  favour  the  occurrence  of  twins  are  but 
little  understood.  Race,  as  we  have  already  shown,  has  an 
important  effect,  as  also  has  heredity,  particularly  when  trans- 
mitted through  the  mother.  This  can  be  understood,  as  there 
is  no  reason  why  a  hereditary  tendency  should  not  be  transmitted 
to  the  production  of  ova  which  contain  two  nuclei,  or  of  two 
ova  at  the  same  time.  It  is,  however,  very  difficult  to  explain 
the  action  of  heredity  transmitted  through  the  father,  inasmuch 
as  in  all  conceptions  sufficient  spermatozoa  gain  access  to  the 
genital  tract  to  fertilise  an  indefinite  number  of  ova.  Still, 
apparent  proof  of  such  influence  is  forthcoming,  even  if  the 
*  Sei-I-Kivai  Medical  Journal,  1902. 


SUPERFECUNDATION  AND  SUPERFCETATION  Si  i 

seemingly  fabulous  cases  recorded  by  Sue  and  by  Velpeau  are 
refused  credence."  The  tendency  to  multiple  pregnancy  is 
apparently  greatest  in  the  first  pregnancy,  and  least  in  the 
second,  and  again  progressively  increases  with  each  subsequent 
pregnancy.!  Lastly,  twins  are  of  more  common  occurrence 
when  the  mother  is  between  twenty-one  and  twenty-eight. 

The  question  of  the  possibility  of  superfecundation  and  of 
superfcetation  is  closely  associated  with  the  mode  in  which 
multiple  pregnancy  occurs.  By  superfecundation,  is  meant  the 
fertilisation  at  a  second  coitus  of  an  ovum  belonging  to  the  same 


Fig.  344.— Diagram  of  Uni-ovular  Twins,  derived  from  Ovum 
with  a  Double  Nucleus. 

Note  the  single  placenta  and  chorion,  and  the  two  amnions. 

period  of  ovulation  as  the  first  ovum,  while  by  superfcetation 
is  meant  the  fertilisation  of  a  second  ovum  belonging  to  a 
subsequent  period  of  ovulation. 

The  possibility  of  superfecundation  has  been  demonstrated  by 
cases  in  which  a  woman  has  had  intercourse  about  the  same  time 
with  a  black  and  a  white  man,  and  has  been  subsequently 
delivered  of  one  pure-blooded  twin  and  one  mulatto.  It  is  of 
frequent  occurrence  amongst  animals.  The  possibility  of  super- 
foetation  occurring  in  a  normally  developed  uterus  is,  to  say  the 
least,  extremely  doubtful.  In  the  first  place,  in  order  that  it 
should  occur,   ovulation   must  continue  during  pregnancy,  and 

*   Vide  Parvin's  '  Science  and  Art  of  Midwifery,'  p.  173. 

t  Vide  Matthew  Duncan's  work  '  On  Fecundity,  Fertility,  and  Sterility.' 


812 


THE  PATHOLOGY  OF  LABOUR 


this,  though  possible,  is  in  all  probability  extremely  rare. 
Secondly,  there  must  be  the  means  of  conjunction  of  the  ovum 
and  the  spermatozoon.  This  is  not  impossible  up  to  the  time  of 
the  fusion  of  the  decidua  vera  and  reflexa  in  the  fourth  month, 
but  it  is  improbable,  as  the  hypertrophy  of  the  uterine  and  tubal 
mucous  membrane  almost  certainly  leads  to  a  functional  blockage 
of  the  lumen  of  the  tube,  while  the  plug  of  mucus  which  forms  in 
the  cervix  at  an  early  period  of  pregnancy  closes  the  cervical 
canal.  Superfoetation  may  occur  under  certain  conditions. 
When  the  first  ovum  develops  in  a  Fallopian  tube,  it  is  possible 


Fig.  345. — Diagram  of  Uni-ovular  Twins,  derived  from  Single 
Germinal  Area. 

Note  the  single  placenta,  chorion,  and  amnion. 


that  a  second  may  subsequently  be  fertilised  and  develop  in  the 
uterus  ;  and,  when  the  uterus  is  double,  an  ovum  may  be  fertilised 
at  one  side  at  one  period,  and  at  the  other  side  at  any  subsequent 
period,  provided  ovulation  occurs.  Cases  of  superfoetation  will 
usually  be  found  to  be  due  to  the  latter  condition,  if  the  patient  is 
carefully  examined.  Cases  in  which  the  difference  in  the  size  of 
two  twins  suggests  the  possibility  of  superfoetation,  but  in  which 
the  uterus  is  single,  are  usually  the  result  of  interference  on  the 
part  of  one  twin  with  the  placental  circulation  of  the  other  in  the 
case  of  a  common  placenta,  or  to  some  pathological  condition  of 
one  twin  which  prevents  its  development. 

Presentations. — As  is  to  be  expected,  the  relative  frequency  of 
malpresentations  is  very  much  more  common   in  twin   than   in 


SEX  AND  DEVELOPMENT  OF  TWINS 


SI3 


single  pregnancies,  on  account  of  the  loss  of  the  adaptation  which 
normally  exists  between  the  shape  of  the  foetus  and  that  of  the 
uterus.  The  combined  statistics  of  Depaul,  Tarnier,  and  Pinard" 
show  the  relative  frequency  of  the  different  presentations  which 
occurred  in  465  cases  of  twins  : — 


Both  vertex 

187 

Face  and  vertex 

Vertex  and  breech 

-     117 

Shoulder  and  vertex 

Breech  and  vertex 

-       74 

Shoulder  and  breech 

Both  breech 

-       48 

Breech  and  face 

Vertex  and  shoulder  - 

16 

Face  and  breech 

Breech  and  shoulder 

6 

Forehead  and  vertex 

Vertex  and  face 

5 

Unknown  - 

Fig.  346.— Twins  presenting 
by  the  Vertex. 


Fig.  347. — Twins  presenting 
by  Vertex  and  Breech. 


From  these  figures  it  appears  that  in  ten  cases  out  of  466  the 
lie  of  the  foetus  was  transverse  or  oblique — i.e.,  a  percentage 
of  2-14.  This  is  a  high  percentage,  but  not  nearly  so  high  as 
that  given  by  Spiegelberg,  who  states  that  in  10  per  cent,  of 
cases  a  transverse  presentation  occurs.  The  statistics  of  Guy's 
Hospital  are  practically  the  same  as  the  French  statistics  which 
we  have  quoted,  i.e.,  2-3  per  cent,  for  transverse  lies. 

Sex  and  Development.- — In  the  case  of  twins  derived  from  the 
same  ovum,  the  sex  is  probably  always  the  same  ;  in  the  case  of 
twins  derived  from  different  ova,  the  sex  may  be  the  same  or  may 

*  Ribemont-Dessaignes,  'Precis  d'Obstetrique,'  3rd  edition,  p.  623. 


8i4 


THE  PATHOLOGY  OF  LABOUR 


vary.     Including  all  cases  of  twin  birth,  the  following  proportion 
was  observed  at  the  Rotunda  Hospital,  amongst  261  cases : — 


Two  males  - 
Two  females 
Male  and  female 


87  times. 
90      „ 


The  weight  of  individual  twins  is  often  below  the  normal — 
a  fact  probably  due  to  their  usual  prematurity,  and  to  the 
mother  being  unable  to  supply  as  large  a  proportion  of  nutriment 
to  each  twin  as  she  would  have  done  to  a  single  child.  The 
average  weight  of  the  two  children  taken  together  is  about 
nine  and  a  half  pounds. 

Diagnosis. — The  diagnosis  of  twin  pregnancy  can  be  made  by 
abdominal  palpation  and  by  auscultation. 

Abdominal  Palpation. — The  first  point  that  is  noticed  by 
abdominal  palpation — if  the  patient  is  at  or  near  full  term — is  the 


Fig.  348. — Twins  presenting  by  Breech  and  Back. 


unusual  size  of  the  uterus,  and  it  may  also  be  possible  to  determine 
that  the  walls  are  more  tense  and  resisting  than  in  a  single 
pregnancy.  Then,  on  palpating  the  foetal  parts,  we  find  that 
they  do  not  follow  one  another  in  their  usual  sequence.  If,  for 
instance,  we  find  a  breech  at  the  fundus,  instead  of  being  able  to 
trace  the  fcetal  outline  along  the  back  to  the  cephalic  pole,  we 
may  find  another  large  part — i.e.,  a  head  or  a  breech — lying 
somewhere  about  the  level  of  the  umbilicus,  or  in  one  or  other 
iliac  fossa  ;  or  we  may  find  an  undue  number  of  limbs  in  the 
neighbourhood  of  the  .umbilicus.  We  can  diagnose  the  existence 
of  twins  by  palpating  two  heads,  two  breeches,  or  two  backs, 
more  than  two  large  parts,  or  more  than  four  limbs.     We  cannot, 


COURSE  OF  LABOUR  IN  MULTIPARA  815 

however,  distinguish  between  many  forms  of  double  monster  and 
twins,  as  the  former  are,  in  fact,  conjoined  twins. 

Auscultation.  —  On  account  of  the  difficulty  of  practising 
abdominal  palpation  in  the  case  of  twins  where  the  uterus  is 
more  distended  and  hence  more  difficult  to  palpate  than  in  a 
single  pregnancy,  we  must  rely  largely  on  the  results  of  careful 
auscultation.  If  two  observers,  listening  at  the  same  moment, 
hear,  and  count,  two  hearts  which  differ  in  rate  both  from  one 
another  and  from  the  maternal  heart,  a  certain  diagnosis  of  twins 
can  be  made.  Collins*  was,  we  believe,  the  first  to  point  out  this 
fact,  and  MacClintockf  supplemented  it  by  diagnosing  the  exist- 
ence of  twins  by  hearing  the  pulsations  of  one  foetal  heart,  while 


Fig.  349. — Twins  lying  transversely. 

at  the  same  time  there  was  a  prolapsed  and  pulseless  funis  in  the 
vagina. 

It  will  be  found  in  practice  that  frequently  the  diagnosis  of 
twins  will  not  be  made  until  one  foetus  is  born,  and  the  uterus  is 
found  to  contain  another. 

Course  of  Labour. — The  usual  sequence  that  occurs  during  the 
expulsion  of  twins  is  the  birth  of  the  first  child,  then  the  birth  of 
the  second,  then  the  placenta  of  the  first,  and  finally  the  placenta 
of  the  second.  In  rare  instances  the  placenta  of  the  first  child 
follows  the  child,  and  then  come  the  second  child  and  its  placenta. 
There  is  very  rarely  any  difficulty  in  delivery,  other  than  that 
which  may  result  from  a  malpresentation,  and  even  the  latter 
condition  is  usually  not  so  serious  as  in  single  pregnancies  on 
account  of  the  smaller  size  of  the  foetus.  Occasionally,  the  twins 
may  become  interlocked   in    such  a   manner  as  to  prevent  the 

*  '  A  Practical  Treatise  on  Midwifery,'  p.  310. 
f  '  Practical  Observations  on  Midwifery,'  p.  320. 


8i6 


THE  PATHOLOGY  OF  LABOUR 


expulsion  of  the  first.  The  management  of  these  cases  will  be 
subsequently  discussed.  As  a  rule,  the  interval  between  the  birth 
of  the  two  children  is  less  than  an  hour.  In  cases  in  which  the 
placenta  of  the  first  child  follows  it,  however,  there  may  be  an 
indefinite  interval,  as,  owing  to  the  prematurity  of  the  children, 
when  once  the  uterus  has  got  rid  of  one  child,  and  consequently 
is  no  longer  overdistended,  the  contractions  may  cease,  and 
pregnancy  may  continue  until  full  term, 


Fig.  350. — Twins  presenting  by  the  Vertex"  and  Breech  as  felt 
by  Abdominal  Palpation. 
The  unshaded  portion  of  the  infants  are  those  which  are  felt  most  distinctly. 

The  following  table  shows  the  interval  between  the  birth  of 
the  first  and  second  foetus  in  1,487  cases  of  twins  recorded  by 
Winckel : — 


Interval. 

Number  of  Cases. 

None           -         -         - 

15  minutes 

30                          -         - 

30  to  45  minutes 

45  to  60 

1  to  22  hours 

364 
386 

301 

52 
156 
228 

MANAGEMENT  OF  MULTIPLE  PREGNANCY  817 

Management. — The  only  necessary  variations  from  the  manage- 
ment of  normal  labour  may  be  mentioned  in  a  very  few  words. 
If  the  first  foetus  is  in  a  longitudinal  lie,  allow  it  to  be  born. 
Then,  palpate  the  uterus,  or,  if  necessary,  make  a  vaginal 
examination  in  order  to  determine  the  lie  of  the  second  foetus. 
If  this  is  longitudinal,  do  nothing ;  if  it  is  transverse,  perform 
podalic  version  and  draw  down  a  leg.  Then,  wait  until  thirty 
minutes  have  elapsed  from  the  birth  of  the  first  child,  and  rupture 
the  membranes,  if  they  have  not  already  ruptured  spontaneously. 
Allow  the  second  child  to  be  born  naturally,  and  conduct  the 
third  stage  in  the  ordinary  manner.  It  is  usually  unnecessary  in 
twin  cases  to  correct  a  face  or  breech  presentation,  or  even  a 
brow,  as  the  small  size  of  the  foetus  will  allow  it  to  be  born 
without  difficulty.  The  object  of  rupturing  the  membranes  is  to 
ensure  the  birth  of  the  second  foetus.  As  has  been  mentioned, 
if  this  is  not  done,  it  is  quite  possible  that  the  contractions  might 
pass  off  for  several  days  or  even  weeks.  Herman,*  indeed,  recom- 
mends that  if  the  placenta  of  the  first  child  follows  it,  pregnancy 
should  be  allowed  to  continue  if  it  will,  in  order  to  ensure  that  the 
second  child  shall  reach  full  term.  We  do  not  think,  however, 
that  this  view  will  commend  itself  to  the  majority  of  obstetricians 
or  of  patients,  inasmuch  as  such  a  course  would  necessitate  all 
the  trouble  and  pain  of  a  second  confinement.  In  exceptional 
cases,  where  the  first  child  was  very  premature,  it  might  be 
desirable  to  follow  his  advice,  but  the  consent  of  the  patient  and 
her  friends  must  first  be  obtained,  and  the  reasons  for  so  acting 
clearly  explained  to  them. 

The  object  of  waiting  for  half  an  hour  before  rupturing  the 
membranes  is  to  afford  the  uterus  time  to  contract  down  upon 
the  second  foetus,  and  also  to  give  it  a  short  rest,  in  order  that, 
when  the  contractions  return,  they  may  be  sufficient  not  only 
to  expel  the  foetus,  but  to  prevent  the  occurrence  of  haemor- 
rhage— a  complication  to  which  the  overdistension  of  the  uterus 
will  always  render  the  patient  prone.  If  the  second  child  is  not 
expelled  within  an  hour  or  so  after  the  rupture  of  the  membranes, 
it  may  be  necessary  to  turn  it  into  a  pelvic  presentation  and 
deliver  by  traction  on  the  legs,  or  to  apply  the  forceps,  according 
as  may  be  thought  best.  If,  however,  there  are  sufficient  contrac- 
tions to  cause  the  presenting  part  to  fix,  the  expulsion  of  the 
foetus  can  usually  be  effected  by  pressure  upon  the  fundus — 
Kristeller's  method. 

A  second  ligature  must  in  all  cases  be  placed  upon  the  funis  of 
the  first  foetus  before  the  funis  is  divided.  This  procedure,  which 
is  only  done  for  convenience  in  single  pregnancies,  is,  in  twin 
cases,  necessary  on  account  of  the  comparative  frequence  with 
which  anastomoses  are  present  between  the  placentae  of  the  two 
children.  In  such  cases,  if  the  second  ligature  was  not  applied, 
the  second  foetus  might  readily  bleed  to  death.     It  is  also  impera- 

*  Op.  cit. 

52 


8i8 


THE  PATHOLOGY  OF  LABOUR 


tive  to  avoid  all  traction  upon  the  first  funis,  as  the  two  cords  are 
occasionally  interlaced,  and  traction  upon  the  first  might  result 
in  causing  kinking  of  the  second,  and  so  cessation  of  the  circula- 
tion through  it. 
.  Complications. — The  proportion  of  cases,  in  which  some  patho- 
logical condition  occurs  in  association  with  twins,  is  considerably 
higher  than  the  proportion  in  single  pregnancies.  The  chief  of 
these  complications  are  as  follows  : — 

Malpresentations  — These  have  been  already  referred  to. 

Interlocking. — This  will  be  discussed  separately. 

Premature  Delivery. — This  is  a  relatively  common  occurrence, 
as  the  following  table  will  show.  It  is  due  to  the  overdistention 
of  the  uterus  by  the  two  children  and  sometimes  by  the  excessive 
quantity  of  liquor  amnii.  The  following  table,  from  the  statistics 
of  Pinard,  is  based  on  the  results  of  150  cases: — 


Duration  of 
Pregnancy.* 

Number  of 
Cases. 

Duration  of 
Pregnancy.* 

Number  of 
Cases. 

9  months 

84      ,. 

8                       - 

74     .. 

7                       " 

42 
24 
35 
10 

14 

64  months 

6          ,,            -         - 
51      "..            "         " 

1'2    :: 

9 

7 
5 

1 

3 

Hydramnios. — An  excessive  amount  of  iiquor  amnii  is  not 
uncommon  in  twin  pregnancies,  particularly  in  cases  in  which 
the  twins  are  developed  from  a  single  ovum.  Its  aetiology  has 
been  already  discussed.  As  a  rule,  only  one  amniotic  sac  is 
affected,  but  more  rarely  both  may  be. 

Eclampsia. — This  condition  is  slightly  more  frequent  in  twin 
than  in  single  pregnancies,  due  in  all  probability  to  the  increased 
work  thrown  upon  the  kidneys  by  the  presence  of  more  than  one 
foetus,  and  also  perhaps  to  the  fact  that  the  ureters  are  more  com- 
pressed in  their  course  through  the  pelvis  in  these  cases. 

Placenta  Prsevia. — It  is  only  natural  to  expect  that  when  the 
placental  area  is  increased  in  size,  the  proportion  of  cases  in 
which  that  area  extends  into  the  lower  uterine  segment  will  be 
also  greater.  Amongst  sixty-two  cases  of  placenta  praevia  recorded 
by  Winckel,  twins  occurred  three  times,  a  proportion  considerably 
in  excess  of  the  normal  rate. 

Post-partum  Haemorrhage. — According  to  Winckel,  post-partum 
haemorrhage  occurs  in  8-5  per  cent,  of  twin  cases.  This  is  prob- 
ably in  the  main  due  to  the  overdistension  and  consequent  paresis 
of  the  muscular  fibres  of  the  uterus.  It  may  also  be  occasionally 
due  to  the  fact  that  the  placental  area  is  larger  than  in  single 
pregnancies,  and  that  sometimes  the  placenta  encroaches  on  the 
*  Pregnancy  is  here  considered  to  consist  of  nine  calendar  months. 


PROGNOSIS  IN  MULTIPLE  PREGNANCY  Si  9 

lower  uterine  segment,  where  the  arrangement  of  the  muscle 
fibres  is  badly  adapted  to  bring  about  the  occlusion  of  the  blood- 
vessels. 

Foetal  Malformation. — An  acardiac  or  an  acephalic  foetus  may 
sometimes  occur  in  the  case  of  twins  derived  from  a  single  ovum, 
and  in  whom  there  is  an  anastomosis  between  their  respective 
placental  circulations.  These  conditions  will  be  discussed  later. 
Also,  in  cases  in  which  the  twins  are  derived  from  a  single 
germinal  area,  they  may  be  conjoined,  and  thus  a  double  monster 
result. 

Placental  Anomalies. — Velamentous  insertion  of  the  cord  is  a 
common  occurrence,  and  sometimes  anastomosing  vessels  are 
found  running  over  the  membranes  between  the  placentae.  Inter- 
lacing of  the  two  cords  may  also  occur,  as  has  been  mentioned, 
and  may  in  some  cases  lead  to  the-  death  of  one  or  both  of  the 
children. 

Prognosis. — The  prognosis  for  the  mother  in  twin  cases  is  better 
than  the  foregoing  list  of  complications  would  lead  one  to  expect, 
and  is  only  slightly  worse  than  in  normal  labour.  This  is  in  great 
part  due  to  the  fact  that  the  small  size  of  the  children  renders 
delivery  comparatively  easy,  even  in  cases  of  malpresentation. 
For  the  foetus,  however,  the  prognosis  is  considerably  more 
serious.  A  certain  number  of  children  die  in  utero,  particularly 
when  derived  from  a  single  ovum,  as  a  result  of  interference  on 
the  part  of  the  stronger  twin  with  the  circulation  of  the  weaker, 
or  to  the  entangling  of  the  cords.  In  such  cases,  one  foetus  may 
die,  and  the  other  go  to  full  term.  The  dead  foetus,  if  small,  may 
then  undergo  fatty  degeneration  and  eventually  be  converted  into 
a  mass  of  adipocere,  or  it  may  become  mummified  and  flattened 
out  against  the  uterine  wall  by  the  living  child.  To  such  a 
foetus,  the  term  foetus  papyvaceus  is  applied. 

Former  statistics  of  the  Rotunda  Hospital*  deal  more  fully 
with  the  mortality  amongst  twins  than  any  other  statistics  with 
which  we  are  acquainted,  and  consequently  we  make  no  excuse 
for  reproducing  Stephenson's!  admirable  summary  of  them  : — 

(1)  The  Influence  of  the  Length  of  Interval  between  the  Births. 
— In  262  cases  the  length  of  the  interval  was  stated.  The  second 
child  was  born  within  fifteen  minutes  of  the  first  in  46*5  per  cent. 
of  cases,  and  during  the  second  quarter  of  an  hour,  in  30*2  per 
cent,  of  cases.  That  is  to  say,  76-7  per  cent,  were  born  within 
half  an  hour,  g-g  per  cent,  were  born  during  the  second  half  hour, 
and  13*3  per  cent,  were  born  more  than  an  hour  after  the  birth  of 
the  first.  Of  those  born  within  the  first  half  hour,  1  in  20  was 
still-born ;  of  those  born  in  the  second  half  hour,  1  in  5  ;  and  of 
those  born  after  an  interval  of  an  hour,  1  in  3-5. 

*  As  collected  by  Collins,  Hardy  and  McClintock,  and  Johnstone  and 
Sinclair. 

j  Encyclopedia  Medica,  vol.  vi.,  p.  208,  article  by  Professor  W.  Stephenson, 
Aberdeen. 

52  —  2 


820  THE  PATHOLOGY  OF  LABOUR 

(2)  The  Influence  of  the  Presentation  on  the  Mortality. — In  the 
first  born  of  the  twins,  the  mortality  of  head  presentation  was 
higher,  that  of  breech  and  footling  presentation  distinctly  less, 
than  in  the  same  presentations  in  single  births.  In  the  second 
born,  head  presentations  were  nearly  twice  as  fatal  as  in  the  first 
born — 11  per  cent,  as  compared  with  6  per  cent.  In  breech  pre- 
sentation, 2-5  per  cent,  only  were  lost.  Of  the  children  that  lay 
transversely  and  were  consequently  turned,  and  of  those  that 
originally  presented  by  the  feet  (132  in  number),  all  were  born 
alive. 

(3)  Total  Infant  Mortality. — Exclusive  of  non-viable  and 
macerated  children,  the  infant  mortality  in  twin  cases  was  7*3  per 
cent,  as  compared  with  27  per  cent,  in  single  births.  Of  the  first 
children,  6-8  per  cent,  were  still-born,  of  the  second  7-8  per  cent. 


Fig.  351. — Locked  Twins. 
Two  small  heads  have  entered  the  pelvis  together. 

These  statistics  are  very  significant,  but  we  cannot  accept 
Stephenson's  conclusion  that  '  instead  of  waiting  half  an  hour,  as 
text-books  still  recommend,  before  rupturing  the  membranes,  the 
delivery  of  the  child  should  be  completed  within  that  time.'  It  is 
difficult  to  understand  how  the  second  foetus  can  come  to  any  harm 
so  long  as  its  membranes  are  intact,  and  the  advantage  to  the 
mother  of  waiting  is  obvious. 

Interlocking  of  the  Infants. — Serious  complications  may 
sometimes  arise  as  a  result  of  interference  with  the  mechanism  of 
labour  by  the  interlocking  of  one  foetus  with  the  other.  Such  a 
complication  may  occur  in  several  ways  : — 

(1)  Each- foetus  presenting  by  the  head,  both  heads  may — if 
small — enter  the  pelvis  together  and  become  impacted  there 
(v.  Fig.  351). 


INTERLOCKING  OF  THE  INFANTS  821 

(2)  The  first  foetus  presenting  by  the  breech,  the  second  by  the 
head,  the  head  of  the  second  may  pass  into  the  pelvis  with  the 
trunk  of  the  first,  and  thus  lie  below  the  head  of  the  first.  In 
such  cases,  impaction  results  from  one  of  several  causes  :  — 

(a)  Want  of  space  in  which  to  rotate,   as  in  the  former 

case. 

(b)  The  chins  become  interlocked  (v.  Fig.  352). 

(c)  The  chin  of  one  fcetus  is  driven  into  the  neck  of  the 

other  O  Fig.  353). 

(d)  Interlocking  of  the  occiput. 

(3)  Each  fcetus  presenting  by  the  head,  one  slightly  in  advance 
of  the  other,  the  head  of  the  second  may  be  driven  into  the  neck 
of  the  first,  and  so  prevent  the  further  descent  of  the  latter. 

(4)  One  fcetus  lying  transversely,  the  other  presenting  either  by 
its  head  or  breech,  the  shoulder  or  chin  of  the  one  lying  longi- 


Fig.  352. — Locked  Twins. 

The  chin  of  the  after-coming  head  of  the  first  child  has  become  interlocked 
with  the  chin  of  the  fore-coming  head  of  the  second  child. 

tudinally  may  be  driven  down  and  interlock  with  the  neck  of  the 
one  lying  transversely  (v.  Figs.  354,  355). 

Diagnosis. — The  diagnosis  of  these  complications  is  made  by 
vaginal  examination  and  abdominal  palpation.  In  the  first  com- 
plication, where  two  heads  descend  simultaneously  into  the  pelvis, 
we  find  by  abdominal  palpation  two  trunks  lying  longitudinally 
in  the  uterus ;  while,  by  vaginal  examination,  we  find  two  small 
solid  tumours  with  the  characteristics  of  the  head  occupying  the 
pelvic  cavity. 

In  the  second  complication,  in  which  the  after-coming  head  of 
the  first  fcetus  interlocks  with  the  fore-coming  head  of  the  second, 
we  find  on  endeavouring  to  deliver  the  head  of  the  first  that,  on 
introducing  the  fingers  into  the  vagina,  they  come  into  contact 
with  the  head  of  the  second  fcetus,  which  is  in  the  pelvic  cavity 
or  at  the  brim.  The  body  of  the  second  foetus  is  also  found  by 
abdominal  palpation,  lying  longitudinally  in  the  uterus. 


822 


THE  PATHOLOGY  OF  LABOUR 


The  recognition  of  the  third  complication  is  more  difficult,  as 
the  interlocking  head  cannot  be  reached  from  the  vagina,  and  the 


FIG-  353- — Locked  Twins. 
The  occiput  of  the  after-coming  head  of  the  first  child  has  become  inter- 
locked with  the  chin  of  the  fore-coming  head  of  the  second  child. 


results  of  abdominal  palpation,  as  will  be  readily  understood,  do 
not  furnish  any  very  definite  information,  save  that  the  case  is  one 


Fig.  354. — Locked  Twins. 

The  shoulder  of  the  first  child  has  been  driven  into  the  neck  of  the 
second  child,  who  is  lying  transversely. 

of  multiple  pregnancy.     A  diagnosis  will  as  a  rule  not  be  arrived 
at  until,  owing  to  delay  in  delivery,  an  attempt  is  made  to  extract 


INTERLOCKING  OF  THE  INFANTS  823 

the  head  in  the  pelvis  with  the  forceps,  when  the  resistance 
offered  to  its  descent  will  attract  attention.  In  all  such  cases, 
the  hand  should  be  introduced  into  the  vagina  and  the  fingers 
passed  above  the  head  to  determine  the  nature  of  the  resistance. 

In  the  case  of  the  fourth  complication,  the  diagnosis  will  be 
made  in  a  similar  manner,  but  here  abdominal  palpation  may 
afford   more   assistance,  as  it  will    show  that    the  second   foetus 


-  IG-  355- — Locked  Twins. 

The  chin  of  the  after-coming  head  of  the  first  child  has  interlocked  with 

the  neck  of  the  second  child,  who  is  lying  transversely. 

is    lying  transversely — a  lie    which    should   always   suggest   the 
possibility  of  a  complication. 

Treatment. — When  two  heads  have  descended  together  into 
the  pelvis,  and  become  impacted  there,  we  must  endeavour  to 
push  up  one  above  the  brim.  The  other  will  then  descend  lower 
and  be  delivered.  If  it  is  found  to  be  impossible  to  keep  the 
second  head  out  of  the  pelvis  while  the  first  is  being  born,  the 


824  THE  PATHOLOGY  OF  LABOUR 

first  foetus  should  be  turned  and  extracted,  but  such  a  course 
is  rarely  necessary.  If  neither  of  the  heads  can  be  pushed 
upwards,  forceps  may  be  applied  to  the  head  which  is  lowest,  and 
an  attempt  made  to  extract  it.  If  this  fails  also,  one  head  must 
be  perforated,  and  as  the  foetus  to  which  the  forceps  has  been 
applied  has  been  subjected  to  the  greater  amount  of  violence,  its 
head  should  be  the  one  to  be  sacrificed. 

When  the  after-coming  head  of  the  first  foetus  becomes  inter- 
locked with  the  fore-coming  head  of  the  second,  the  second  head 
must,  if  possible,  be  set  free  and  pushed  upwards.  The  first  head 
can  then  be  extracted.  If  this  cannot  be  done,  and  if  the  children 
are  small,  an  attempt  may  be  made  to  extract  the  second  foetus 
with  the  forceps  past  the  body  of  the  first,  and  then  to  deliver  the 
first.  If  this  also  fails,  the  first  foetus  must  be  decapitated,  its 
head  pushed  upwards,  then  the  second  foetus  extracted,  and  lastly 
the  head  of  the  first.  The  first  foetus  should  always  be  decapitated 
in  such  a  case,  as,  owing  to  the  pressure  its  funis  has  undergone, 
it  is  almost  certainly  dead. 

When  both  children  present  by  the  head,  and  the  head  of  the 
second  is  driven  into  the  neck  of  the  first,  the  head  of  the  second 
should  be  pushed  upwards,  and  the  first  foetus  then  extracted 
with  the  forceps. 

When  the  first  foetus  presents  by  the  head,  and  its  shoulder 
becomes  locked  against  the  neck  or  body  of  the  second,  which  is 
lying  transversely,  an  attempt  must  be  made  to  push  away  the 
body  of  the  second  foetus  with  the  fingers  passed  into  the  uterus. 
If  this  can  be  done,  the  first  child  is  extracted  with  the  forceps, 
and  then  the  second  turned  and  extracted.  When  the  first  foetus 
presents  by  the  breech,  and  its  chin  becomes  locked  against  the 
neck  of  the  second,  which  is  lying  transversely,  the  treatment  is 
similar,  and  we  attempt  to  push  away  the  body  of  the  second, 
and  then  to  extract  the  first.  If  that  is  not  possible,  the  first 
must  be  decapitated,  its  body  removed,  then  the  second  foetus 
turned  and  extracted,  and  lastly  the  head  of  the  first  removed. 


CHAPTER  VII 

COMPOUND    PRESENTATIONS— PRESENTATION    AND 
PROLAPSE  OF  THE  CORD 

Compound  Presentations — Presentation  of  a  Hand  or  Arm  with  the  Head 
— Presentation  of  the  Foot  or  Feet  with  the  Head — Presentation  of 
Hands  and  Feet — Presentation  of  a  Hand  with  the  Breech.  Presentation 
and  Prolapse  of  the  Cord — Treatment — Reposition — Podalic  Version — 
Immediate  Delivery. 

COMPOUND  PRESENTATIONS 

Under  the  term  Compound  Presentations  we  include  the  follow- 
ing conditions  : — Presentation  of  a  hand  or  arm  with  the  head. 
Presentation  of  a  foot  or  feet  with  the  head.  Presentation  of  a 
hand  and  foot  or  hands  and  feet  together.  Presentation  of  a 
hand  with  the  breech. 

Presentation  of  a  Hand  or  Arm  with  the  Head. 

In  this  presentation,  the  head  presents  and  the  hand  or  even 
the  arm  is  prolapsed  alongside  it,  so  that  the  one  or  the  other  is 
felt  from  the  vagina.  In  some  cases,  it  may  be  possible  to  feel 
only  the  tips  of  the  fingers,  and  this,  perhaps,  is  commonest.  In 
other  cases,  the  hand,  or  even  the  entire  forearm,  may  lie  below 
the  head.  In  very  exceptional  cases,  the  arm  may  lie  behind  the 
head  in  relation  to  the  occipital  prominence.  This  condition  is 
also  known  as  nuchal  position  or  dorsal  displacement  of  the 
arm,  and  was  first  described  by  Simpson."  ■  It  is  closely  akin  to 
the  nuchal  position  of  the  arm  which  sometimes  occurs  in 
breech  presentation,  and  which  has  been  already  alluded  to. 

Frequency. — The  proportion  of  cases  in  which  the  hand  is  found 
beside  the  head  varies  considerably  according  to  the  statistics  of 
different  writers.  Thus,  at  Guy's  Hospital,  amongst  22,980 
births,  the  proportion  of  cases  in  which  the  hand  had  descended 
was  only  one  in  425,  while,  according  to  various  aggregated  conti- 
nental statistics,!  the  proportion  amongst  12,202  cases  was  one  in 
55*7.     In  the  latter  statistics,  however,  all   cases  in  which  the 

*  Edinburgh  Monthly  Journal,  April-May,  1850. 

y  Hugenberger,  St.  Petersburg  ;   Pernice,  Halle  ;  Winckel,  Dresden. 

825 


8a6 


THE  PATHOLOGY  OF  LABOUR 


hand  prolapsed  beside  the  head  are  included,  whether  it  was 
accompanied  by  a  foot  or  not,  while  it  is  possible  that  the  Guy's 
Hospital  statistics  refer  to  cases  of  prolapse  of  the  hand  alone. 
Still,  even  if  cases  in  which  there  was  an  associated  prolapse  of 
a  foot  or  feet  are  excluded,  the  continental  statistics  show  a 
very  much  higher  rate. 

Causes. — The  same  conditions,  which  we  have  already  noticed 
as  causes  of  malpresentations  of  the  foetus,  and  especially  those 
which  prevent  the  head  from  descending  into  the  lower  uterine 
segment,  may  also  be  the  cause  of  prolapse  of  the  hand  or  arm. 
The  chief  of  these  causes  are  flattened  pelvis,  obliquities  of  the 


Fig.  356. — Presentation  of  an  Arm  with  the  Head. 

Note  also  the  associated  presentation  of  the  posterior  parietal  bone 
(anterior  asynclitism).     (After  Schaeffer. ) 


uterus  and  pendulous  abdomen,  twins,  and  an  unusually  large  or  a 
very  small  foetal  head.  The  sudden  escape  of  the  liquor  amnii  in 
hydramnios  is  a  not  uncommon  cause,  as  the  rush  of  fluid  may 
carry  down  a  limb. 

Diagnosis. — The  diagnosis  can  be  only  made  by  vaginal  examina- 
tion. If  the  hand  is  beside  the  presenting  part,  it  is  readily  felt. 
When,  however,  it  is  behind  the  back — the  nuchal  position,  the 
condition  will  not  be  recognised  until  after  the  birth  of  the  head, 
unless  it  obstructs  delivery.  Then,  the  condition  may  be  deter- 
mined by  passing  the  fingers  above  the  presenting  part  and 
feeling  the  arm  as  it  lies  behind  the  neck. 

Effect  on  Labour.— The  prolapse  of  an  arm  alongside  the  head 


THE  TREATMENT  OF  COMPOUND  PRESENTATIONS  827 

may  affect  labour  in  one  of  three  ways.  If  the  head  is  still  free 
above  the  brim,  the  prolapse  may  bring  about  a  change  of  pre- 
sentation from  a  vertex  to  a  shoulder  (Michaelis")  or  to  a  face 
presentation  (Winckelf).  If  the  head  has  descended  into  the 
brim,  the  presence  of  the  arm  may  cause  a  descent  of  the  posterior 
parietal  bone,  or  may  cause  increased  difficulty  in  or  complete 
arrest  of  delivery,  owing  to  the  greater  size  of  the  presenting  part, 
which  has  to  pass  through  the  pelvis.  On  the  other  hand,  in  the 
case  of  a  small  fetal  head  or  a  large  pelvis,  labour  may  be  un- 
affected, or,  in  some  cases,  as  the  head  descends,  the  prolapsed 
hand  may  be  retarded  by  the  friction  of  the  pelvic  wall,  and  so 
brought  back  again  into  its  proper  position  as  the  head  descends.  A 
nuchal  position  of  the  arm  may  result  in  this  manner,  the  forearm 
being  pushed  upwards  and  backwards  by  the  pelvic  brim  or  walls. 

Treatment. —  If  the  prolapse  of  a  hand  or  arm  is  discovered 
while  the  head  is  still  free  above  the  brim  and  the  membranes 
unruptured,  it  may  be  possible  to  bring  about  the  correction  of 
the  condition  by  the  postural  method.  Place  the  patient  upon 
the  side  opposite  to  that  on  which  the  limb  has  prolapsed,  with 
the  view  of  correcting  the  obliquity  of  the  foetus  which  caused 
the  prolapse  and  at  the  same  time  of  drawing  up  the  limb.  If  this 
procedure  is  successful,  keep  the  patient  in  this  position  until  the 
head  descends  into  the  brim.  If  the  procedure  is  unsuccessful, 
pass  the  hand  into  the  vagina,  and  endeavour  to  replace  the  arm. 
This  can  usually  be  done  if  the  head  is  not  fixed,  but  it  is  not 
always  possible  to  keep  it  up.  As  soon  as  the  arm  has  been 
replaced,  push  the  head  into  the  brim,  and  if  it  descends  into  and 
fills  the  latter  maintain  it  in  this  position  by  means  of  a  tight 
abdominal  binder.  If,  however,  it  does  not  fill  the  brim,  and 
there  is  room  for  the  arm  to  again  descend  beside  it,  examine 
the  patient  vaginally  in  a  short  time,  and,  if  the  arm  has  again 
prolapsed,  perform  podalic  version  and  bring  down  a  foot.  If, 
however,  the  head  is  very  small  in  comparison  with  the  pelvis, 
the  arm  may  be  allowed  to  remain  prolapsed,  as  its  presence  will 
not  interfere  with  delivery.  If  the  nature  of  the  case  is  not 
recognised  until  the  head  has  passed  the  brim,  and,  conse- 
quently, reposition  is  impossible,  leave  the  case  to  Nature,  until 
some  indication  for  immediate  delivery  appears.  Then,  the 
forceps  may  be  applied,  and  the  foetus  extracted.  In  such  cases, 
care  must  be  taken  to  so  apply  the  forceps  that  the  prolapsed 
hand  or  arm  is  not  included  between  the  blade  and  the  foetal  head. 

In  replacing  a  prolapsed  arm,  the  patient  may  be  placed  upon 
the  side  at  which  the  arm  is  found,  as  the  weight  of  the  foetal 
body  will  then  tend  to  carry  the  head  to  the  opposite  side,  and 
this  will  provide  more  room  for  the  operator's  hand.  As  soon  as 
the  arm  has  been  completely  pushed  above  the  head,  the  patient 
may  be  again  placed  on  the  opposite  side  to  that  at  which  the 
prolapsed  limb  lay,  in  order  to  correct  the  foetal  obliquity. 
*  'Das  engen  Becken,'  etc.,  p.  184.  f  Op.  tit.,  p.  384. 


828  THE  PATHOLOGY  OF  LABOUR 

The  management  of  a  case  of  nuchal  position  of  the  arm  is 
more  difficult.  If  the  head  is  free,  Sir  J.  Simpson,  who  described 
the  condition, *  recommended  to  draw  the  arm  down  beside  the 
head,  when  the  case  becomes  identical  with  that  we  have  just 
described,  and  may  be  treated  accordingly.  Another  method 
consists  in  rotating  the  head  with  the  hand  in  the  vagina  in  the 
direction  to  which  the  fingers  of  the  displaced  hand  point,  in  the 
hope  that  the  friction  of  the  soft  parts  may,  by  keeping  the 
arm  steady,  restore  the  normal  relations.  Herman  considers  that 
podalic  version  is  preferable  to  either  of  these  methods,  but,  if 
this  is  to  avail  so  far  as  the  foetus  is  concerned,  the  arm  must 
still  be  replaced,  as  a  nuchal  position  is  almost  equally  difficult 
to  manage  when  it  occurs  with  an  after- coming  head.  It  is  most 
unlikely  that  a  nuchal  position  of  the  arm  will  be  recognised  until 
the  head  has  descended  into  the  pelvis,  inasmuch  as  it  will  in  all 
probability  not  cause  any  obstruction  prior  to  this,  and  then,  save 
in  the  case  of  a  very  small  head,  even  reposition  will  be  impos- 
sible. In  many  cases,  a  nuchal  position  will  not  be  recognised, 
and  in  such  cases  the  application  of  the  forceps  is  usually 
necessary  on  account  of  delay,  or,  if  delivery  by  the  forceps  is 
impossible,  we  may  be  compelled  to  perform  perforation. 

.Prognosis. — In  the  cases  of  prolapsed  arm  or  hand  at  Guy's 
Hospital,  to  which  we  have  already  alluded,  14-8  per  cent,  of  the 
children  were  born  dead.  In  nuchal  position  of  the  arm,  the  foetal 
mortality  is  probably  considerably  higher. 

Presentation  of  a  Foot  or  Feet  with  the  Head. 

In  this  presentation,  the  foetus  is  so  doubled  upon  itself  that 
one  or  both  feet  come  to  lie  at  the  level  of,  or  even  slightly  below, 
the  presenting  head. 

Frequency. — Amongst  the  12,202  continental  cases  to  which  we 
have  referred  in  the  preceding  sections,  presentation  of  the  foot  or 
feet  alongside  the  head  occurred  in  14,  a  proportion  of  one  in 
871*5.  In  several  of  these  cases  there  was  an  accompanying 
prolapse  of  one  or  both  hands. 

^Etiology. — The  causation  of  this  condition  is  probably  very 
similar  to  that  of  presentation  of  the  hand  and  head.  It  may 
also  occur,  temporarily,  during  the  performance  of  combined  or 
internal  podalic  version. 

Diagnosis.  —  The  diagnosis  can  be  only  made  by  vaginal 
examination,  though  the  presence  of  a  prolapsed  foot  may  be 
suspected  from  the  results  of  abdominal  palpation. 

Effect  upon  Labour. — The  probable  effect  upon  labour  of  the 
prolapse  of  a  foot  beside  the  head  is  that  the  latter  is  gradually 
pushed  away  from  the  pelvic  brim,  while  the  arm  descends 
deeper,  a  presentation  of  the  arms  and  feet  eventually  resulting, 
and  a  transverse  lie  of  the  foetus. 

*  Edinburgh  Monthly  Journal,  April-May,  1850. 


PRESENTATION  AND  PROLAPSE  OF  THE  CORD  829 

Treatment.- — If  the  membranes  are  intact,  the  breech  must  be 
pushed  by  external  manipulations  to  the  fundus,  and  the  head 
into  the  brim.  The  foetus  may  be  then  maintained  in  this 
position  by  an  abdominal  binder,  supplemented  if  necessary  by 
pads  placed  at  each  side  of  the  foetal  body  with  the  object  of 
maintaining  its  longitudinal  lie.  If  this  procedure  is  impossible, 
or  if  the  foot  again  descends,  podalic  version  must  be  performed, 
the  foot  drawn  down,  and  the  head  pushed  up  to  the  fundus. 

Presentation  of  Hands  and  Feet. 

This  condition  is  only  a  variety  of  a  transverse  lie  of  the  foetus, 
and  need  not  be  discussed  again. 

Presentation  of  a  Hand  with  the  Breech. 

This  is  not  a  condition  of  any  great  importance,  as  there  is 
usually  ample  room  for  a  hand  to  pass  through  the  pelvis  beside 
the  breech  on  account  of  the  compressible  nature  of  the  latter. 
Further,  in  many  cases,  as  the  breech  descends,  the  hand  will  be 
pushed  up  by  the  pelvic  brim.  Presentation  of  the  hand  with  the 
breech  occurred  7  times  in  8,210  cases  of  labour  recorded  by 
Hugenberger,"  a  proportion  of  one  in  1174-3. 


PRESENTATION  AND  PROLAPSE  OF  THE 
UMBILICAL  CORD 

Presentation  of  the  cord  is  the  term  applied  to  the  condition  in 
which  the  cord  lies  below  the  presenting  part,  the  membranes 
being  still  unruptured.  Prolapse  of  the  cord  is  the  term  applied 
to  the  same  condition  after  the  membranes  have  ruptured 
(v.  Fig.  357). 

Frequency. — The  relative  frequency  with  which  presentation 
and  prolapse  of  the  cord  occurs  in  different  hospitals  and  countries 
varies  very  greatly.  As  will  be  seen  when  discussing  the  aetiology 
of  these  conditions  their  frequency  is  very  closely  connected  with 
the  proportion  of  cases  of  contracted  pelvis,  as  the  latter  condition 
both  itself  predisposes  to  prolapse  and  presentation,  and  also  pre- 
disposes to  conditions — such  as  malpresentations— which  them- 
selves favour  prolapse.  The  total  of  three  aggregated  sets  of 
German  statistics!"  show  that  prolapse  occurred  135  times  out  of 
10,903  cases — a  proportion  of  one  in  80*7,  while,  according  to 
statistics  collected  by  Churchill,  it  occurred  304  times  out  of 
50,061  cases,  a  proportion  of  one  in  164.  According  to  the 
statistics  of   the  Rotunda  Hospital   for  the  last  fourteen  years, 

*  '  Bericht  liber  das  Gebarhaus  der  Grossfurstin  Helene  Paulo wna,'  1863, 
p.  16. 

+  Hecker,  Abegg,  and  Crede. 


830 


THE  PATHOLOGY  OF  LABOUR 


prolapse  occurred  130  times  in  20,000  cases  of  labour,  a  propor- 
tion of  one  in  153*84.  Presentation  of  the  cord  is  considerably 
rarer  than  is  prolapse. 

^Etiology. — Presentation  of  the  cord  differs  somewhat  from  pro- 
lapse in  its  aetiology.  All  cases  of  presentation  become  cases  of 
prolapse  as  soon  as  the  membranes  rupture,  unless  the  cord  has 
been  previously  replaced,  but  the  majority  of  cases  of  prolapse  do 
not  commence  as  cases  of  presentation.  Presentation  is,  so  to 
speak,  a  primary  condition,  that  is,  it  is  present  at  the  commence- 


Fig.  357. — Presentation  and  Prolapse  of  the  Umbilical  Cord. 

A,  Presentation  of  the  cord  ;  B,  prolapse  of  the  cord.     Note  the  presence 
of  pelvic  contraction. 

ment  of  labour.  In  most  cases  of  prolapse,  on  the  other  hand, 
the  cord  usually  occupies  a  normal  position  above  the  presenting 
part  until  the  membranes  rupture,  when  it  is  swept  down  by  the 
escaping  liquor  amnii. 

Presentation  of  the  cord,  as  a  rule,  results  from  one  of  three 

conditions  : — An  abnormally  long  cord ;  a  velamentous  or  marginal 

insertion  of  the  cord ;   and  an  abnormally  low  situation  of  the 

placenta.     Hecker*  found  that  in  cases  of  presentation  of  the  cord 

*  '  Deutsche  Klinik,'  I.  165;  and  II.  103. 


CAUSES  OF  PROLAPSE  OF  THE  CORD  831 

associated  with  a  head  presentation,  the  average  length  of  the 
former  was  a  little  above  twenty-eight  inches.  As  the  average 
length  of  the  cord  is  only  twenty-two  inches,  this  means  an 
average  difference  of  six  inches.  Another  observer  (Hugen- 
berger)  has  shown  that  marginal  insertion  is  found  three  times 
as  often  in  cases  of  presentation  of  the  cord  as  is  central  inser- 
tion. Presentation  of  the  cord  also  occurs  more  frequently  in 
cases  of  low  insertion  of  the  placenta  than  in  cases  of  its  normal 
insertion,  and  YYinckel  met  with  four  cases  amongst  sixty-two 
cases  of  placenta  praevia. 

Prolapse  of  the  cord  is  the  natural  sequence  of  presentation  in 
cases  in  which  the  presentation  is  not  replaced,  but  this  is  not  its 
common  cause.  Prolapse,  as  a  rule,  is  the  result  of  a  combination 
of  two  conditions : — a  presenting  part  which  does  not  fill  the 
lower  uterine  segment,  and  a  sufficient  amount  of  liquor  amnii  to 
create  the  force  necessary  to  carry  the  cord  below  the  presenting 
part  when  the  membranes  rupture.  The  necessity  for  the  presence 
of  these  two  conditions  is  very  obvious.  If  the  presenting  part 
fills  the  lower  uterine  segment  completely,  the  liquor  amnii  which 
is  round  the  body  does  not  escape  when  the  membranes  rupture, 
as  the  presenting  head  acts  as  a  ball-valve  and  prevents  it  from 
doing  so ;  consequently,  there  is  neither  room  for  the  cord  to 
prolapse  nor  force  to  drive  it  downwards.  Moreover,  even  if  the 
presenting  part  does  not  fill  the  lower  segment,  the  cord  will  not 
prolapse  unless  there  is  some  force  to  drive  or  carry  it  down.  This 
force  is  supplied  by  the  sudden  rushing  away  of  the  liquor  amnii, 
and,  if  the  latter  is  scanty  in  amount,  the  necessary  force  is  want- 
ing and  prolapse  does  not  occur.  These  two  conditions  may  then 
be  regarded  as  invariably  present  in  all  cases  of  prolapse  of  the 
cord  occurring  independently  of  a  previous  presentation,  that  is, 
as  the  cause  of  the  greater  proportion  of  cases.  The  various 
conditions,  which  interfere  with  the-  normal  adaptation  which 
should  exist  between  the  presenting  part  and  the  lower  uterine 
segment,  will  thus  be  always  found  associated,  as  predisposing 
factors,  with  prolapse  of  the  cord,  the  actual  exciting  cause  being 
in  every  case  the  sudden  rushing  away  of  the  liquor  amnii.  The 
principal  predisposing  factors  are  as  follows  : — ■ 

(1)  Pelvic  Contraction. — Pelvic  contraction  favours  prolapse  of 
the  cord  both  per  se  by  preventing  the  descent  of  the  head  into  the 
lower  uterine  segment,  and  on  account  of  the  abnormalities  which 
it  tends  to  cause  in  the  presentation  of  the  foetus.  Winckel  met 
with  prolapse  of  the  cord  in  ten  per  cent,  of  cases  of  contracted 
pelvis,  while  other  writers  state  the  percentage  to  be  even  higher. 

(2)  Faulty  Conditions  of  the  Uterus.— Any  abnormality  of  the 
uterus  that  prevents  the  descent  of  the  head  into  the  lower  uterine 
segment  or  that  favours  the  occurrence  of  malpresentations  also 
predisposes  to  prolapse.  Such  abnormalities  are  mechanical 
obstacles  to  descent,  as  myomata,  extreme  laxity  of  the  uterine 
muscle,  and  many  of  the  various  forms  of  maldevelopment.     As 


832 


THE  PATHOLOGY  OF  LABOUR 


is  to  be  expected,  prolapse  occurs  more  frequently  in  multiparous 
women  than  in  primiparae,  and  the  result  of  various  collected 
statistics*  shows  that  it  occurs  about  three  and  a  half  times  as 
frequently  in  one  as  in  the  other. 

(3)  Malpresentation  of  the  Foetus.  —  A  vertex  presentation 
alone  is  properly  adaptable  to  the  shape  of  the  lower  uterine 
segment.  All  other  presentations  fill  the  lower  segment  more 
or  less  incompletely,  and,  consequently,  afford  room  for  the 
descent  of  the  cord  if  the  liquor  amnii  escapes  suddenly.  It  is 
instructive  to  compare  the  relative  frequency  of  the  different  pre- 
sentations, first,  in  all  cases  of  labour,  and,  secondly,  in  cases 
complicated  by  prolapse  of  the  cord,  as  such  a  comparison  shows 
very  clearly  the  influence  of  malpresentations  :  — 


Vertex. 

B:eech. 

Face  and  Brow. 

Shoulder. 

Usual  percentage  of  pre- 
sentations 

Percentage  in  cases  of  pro- 
lapse of  cord-j- 

55'53 
563 

3  "ii 

25 '2 

o-8 

I"0 

0-56 
i7-5 

Faulty  attitude  of  the  foetus,  such  as  the  prolapse  of  a  limb,  also 
favours  prolapse  of  the  cord. 

(4)  Multiple  pregnancy,  abnormalities  in  the  development  of  the 
foetus,  excessive  quantity  of  liquor  amnii,  and  low  insertion  of  the 
placenta,  may  finally  be  all  grouped  together  as  predisposing 
causes  of  prolapse,  as  they  all  tend  to  a  greater  or  less  degree  to 
prevent  the  normal  adaptation  of  the  presenting  part  to  the  lower 
uterine  segment.  In  the  case  of  hydramnios,  there  is  the  additional 
exciting  factor  of  an  increased  rush  of  liquor  amnii  when  the 
membranes  rupture. 

Consequences. — Presentation  or  prolapse  of  the  cord  has  no 
effect  on  the  mother,  but  the  effect  on  the  foetus  is  very  consider- 
able. During  each  contraction  of  the  uterus,  the  presenting  part 
is  driven  downwards  and  presses  against  the  cord.  This  pressure 
is  not  sufficient  to  be  of  any  consequence  until  the  membranes 
rupture,  but,  as  soon  as  this  occurs,  the  cord  is  compressed 
between  the  presenting  part  and  the  undilated  portion  of  the 
cervix — if  dilatation  is  not  complete,  or,  if  the  head  has  descended 
into  the  pelvic  cavity,  between  the  presenting  part  and  the  pelvic 
wall.  Such  compression  obstructs  the  circulation  in  the  umbilical 
vessels,  and,  unless  relieved  rapidly,  brings  about  a  slowing  of  the 
foetal  heart,  followed  by  its  gradual  cessation  and  the  consequent 
death  of  the  foetus. 

Diagnosis. — The  diagnosis  of  prolapse  or  presentation  of  the 
cord  can  be  readily  made  by  vaginal  examination.    In  presentation, 


*  Winckel,  oJ>.  cit. 


f  Winckel — collected  cases. 


THE  TREATMENT  OF  PROLAPSE  OF  THE  CORD  833 

the  cord  is  felt  below  the  presenting  part  and  is  recognised  by  its 
characteristic  shape  and  by  the  fact  that  it  pulsates  if  the  foetus 
is  alive.  In  prolapse,  a  loop  of  the  cord  has  usually  descended 
into  the  vagina,  or  it  may  pass  through  the  vulva  and  be  found 
externally.  In  cases  in  which  it  has  not  been  compressed,  it  is 
full  of  blood  and  pulsates,  but,  if  the  death  of  the  foetus  has  occurred, 
it  is  usually  more  or  less  flaccid.  Presentation  of  the  cord  may 
pass  unrecognised  when  the  presenting  part  of  the  foetus  is  some 
little  way  above  the  uterine  orifice,  as  the  cord  may  not  be 
reached  by  the  examining  finger.  If  it  is  felt,  however,  it  cannot 
be  mistaken  for  anything  else,  as  its  shape  is  characteristic. 

Presentation  or  prolapse  of  the  cord  cannot  be  diagnosed  by 
abdominal  palpation.  The  attention  of  the  obstetrician  will, 
however,  be  drawn  to  the  possible  presence  of  such  a  condition 
if  he  finds  the  presenting  part  free  above  the  brim  at  a  time  at 
which  it  ought  to  be  fixed.  Auscultation  of  the  foetal  heart  may 
sometimes  lead  to  a  diagnosis.  If  we  find  that  the  rate  of  the 
heart  diminishes  very  considerably  during  a  contraction  of  the 
uterus,  while  it  is  more  rapid  than  normal  in  the  interval  between 
the  contractions,  it  is  strong  evidence  that  intermittent  compres- 
sion of  the  cord  is  occurring.  Such  compression  may  result  from 
causes  other  than  presentation  or  prolapse,  but  these  conditions 
are  its  most  common  cause.  Under  normal  circumstances,  the 
foetal  heart-rate  falls  during  a  contraction  from  140  beats  per 
minute  to  from  80  to  68,  while,  in  cases  in  which  the  cord  is 
compressed,  the  rate  may  fall  from  150  to  160  between  the  con- 
tractions to  45  to  50  during  the  contraction.  The  presence  of  a 
funic  souffle  is  also  suggestive  of  compression  of  the  cord,  and  this 
compression  may  be  due  to  presentation  or  prolapse. 

Treatment. — When  presentation  or  prolapse  of  the  cord  occurs, 
the  death  of  the  foetus  will  almost  certainly  result  during  the  stage 
of  expulsion  in  consequence  of  the  pressure  on  the  cord,  unless 
the  condition  is  remedied  or  the  stage  is  very  short.  So  long  as 
the  membranes  remain  intact,  the  danger  of  compression  is  not 
very  great,  but,  once  their  rupture  occurs,  compression  usually 
immediately  results.  There  is  one  favourable  circumstance 
attending  these  cases,  and  to  which  many  infants  owe  their  life. 
The  same  conditions  which  favour  prolapse  of  the  cord,  i.e.,-  a 
want  of  adaptation  between  the  presenting  part  and  the  lower 
uterine  segment,  tend  to  minimise  the  danger  of  compression 
during  the  early  part  of  the  stage  of  expulsion.  The  reason  of 
this  is  that  the  same  condition  that  prevents  the  presenting  part 
from  exactly  filling  the  lower  uterine  segment,  also  prevents  it 
from  exactly  filling  the  pelvic  brim  or  cavity,  and  that,  con- 
sequently, there  may  be  sufficient  room  at  one  side  of  the  pelvis 
for  the  prolapsed  cord  to  lie  without  being  compressed.  Pre- 
sentation or  prolapse  of  the  cord  is  almost  always  fatal  to  the 
foetus  when  it  occurs  in  a  patient  in  whom  the  pelvis  is  normal, 
and  in  association  with  a  vertex  presentation,  unless  the  stage 

53 


834  THE  PATHOLOGY  OF  LABOUR 

of  expulsion  is  very  short  indeed.  On  the  other  hand,  the  fetus 
has  a  fair  prospect  of  escape  when  prolapse  occurs  in  the  case  of 
a  slightly  contracted  pelvis,  and  in  association  with  a  pelvic  pre- 
sentation. Indeed,  so  good  is  this  prospect,  that,  as  we  shall 
see,  a  recognised  method  of  treatment  in  these  cases  is  the  sub- 
stitution of  a  pelvic  for  a  cephalic  presentation. 

In  discussing  the  treatment,  we  need  not  differentiate  between 
presentation  and  prolapse,  but  will  for  the  time  include  them  both 
under  the  term  prolapse. 

Prolapse  of  the  cord  may  be  treated  in  one  of  the  following 
ways,  according  to  the  'exact  conditions  present : — Reposition,  the 
cord  being  replaced  above  the  presenting  part ;  the  substitution 
of  a  pelvic  presentation  for  a  cephalic  presentation  ;  or  immediate 
delivery. 

Reposition. — By  the  reposition  of  the  cord  is  meant  its  replace- 
ment above  the  presenting  part,  in  order  that  it  may  not  be  com- 
pressed during  labour.  Reposition  can  be  effected  in  one  of  three 
ways  : — Postural  reposition  ;  manual  reposition  ;  or  instrumental 
reposition. 

(i)  Postural  Reposition. — Postural  reposition  is  effected  by 
placing  the  patient  in  such  a  position  that  the  fcetus  and  the  cord 
tend,  under  the  influence  of  gravity,  to  drop  towards  the  fundus 
of  the  uterus,  and  so  to  draw  away  from  the  uterine  orifice  the 
portion  of  cord  that  is  presenting.  In  order  that  it  may  be 
successfully  carried  out,  the  membranes  must  be  intact,  that  is 
to  say,  the  case  must  be  one  of  presentation  of  the  cord,  and  the 
presenting  part  must  not  be  fixed  in  the  pelvic  brim.  If  these 
conditions  are  present,  the  method  may  be  given  a  trial,  as,  if  it 
succeeds,  it  offers  the  best  prospect  of  saving  the  life  of  the  fetus, 
and  at  the  same  time  is  free  from  danger  so  far  as  the  mother  is 
concerned,  as  it  does  not  necessitate  any  intra-uterine  interference. 
The  best  position  in  which  to  place  the  patient  is  the  knee-chest 
position,  in  which  she  kneels,  and  then  bends  forward  until  her 
chest  is  almost  in  contact  with  the  bed  (v.  Fig.  192).  The  uterus 
then  falls  forward  under  the  influence  of  gravity  and  becomes 
almost  vertical,  and  the  presenting  part  and  the  cord  tends  to  fall 
away  from  the  uterine  orifice.  The  fingers  are  then  passed  into 
the  vagina,  and  an  examination  is  made  to  ascertain  whether  the 
cord  has  slipped  back.  If  it  has  not  done  so,  the  presenting  part 
is  pushed  away  from  the  brim,  and  the  foetus  moved  from  side  to 
side  by  pressure  applied  by  an  assistant  through  the  abdominal 
wall.  By  this  means,  the  cord  may  be  made  to  fall  back.  If,  on 
the  other  hand,  the  cord  has  fallen  back,  the  assistant  presses  the 
presenting  part  into  the  pelvic  brim,  and  the  patient  is  at  the 
same  time  gently  turned  over  and  placed  again  in  the  dorsal 
position.  The  fingers  are  kept  in  the  vagina  during  this  move- 
ment to  ascertain  that  the  cord  does  not  again  fall  down.  If  it 
remains  up,  and  if  the  os  is  at  least  half  dilated,  the  membranes 
may  be  ruptured.     The  presenting  part  must  then  be  kept  in  the 


REPOSITION  OF  THE  PROLAPSED  CORD  835 

brim  until  the  uterine  contractions  fix  it,  either  by  manual  pres- 
sure applied  through  the  abdominal  wall,  or  by  means  of  a  tight 
abdominal  binder.  If  the  cord  again  prolapses  as  soon  as  the 
patient  is  brought  back  to  the  dorsal  position,  it  is  better  to  again 
place  her  in  the  knee-chest  position  and  to  keep  her  in  it  until 
the  contractions  fix  the  presenting  part.  Some  patients,  however, 
would  find  it  a  physical  impossibility  to  stay  for  long  in  such 
a  position,  and,  in  their  case,  a  modified  Trendelenburg  position 
may  be  substituted.  A  ready  means  of  extemporising  a  support 
which  will  keep  the  patient  in  the  latter  position  consists  in  laying 
a  wooden  chair  on  its  face  along  the  bed  in  such  a  manner  that 
the  back  forms  an  inclined  plane.  The  back  is  then  padded 
with  pillows,  and  the  patient  is  placed  on  it  as  shown  in  Fig.  193. 
She  must  remain  in  this  position  until  the  presenting  part  is  fixed, 
and  then  she  may  be  allowed  to  return  to  the  dorsal  position. 

(2)  Manual  Reposition. — Manual  reposition — the  reposition  of 
the  cord  by  the  hand  or  fingers  passed  into  the  uterus — may  be 
tried  in  all  cases  in  which  postural  reposition  fails,  and  in  which 
the  necessary  conditions  for  its  performance  are  fulfilled.  These 
conditions  are  that  the  presenting  part  is  not  fixed  in  the  pelvic 
brim,  and  that  the  uterine  orifice  is  sufficiently  dilated  to  allow 
the  hand  to  be  introduced  as  far  into  the  uterus  as  is  necessary. 
Manual  reposition  will  be  best  performed  with  the  patient  in  the 
knee-chest  position,  unless  an  anaesthetic  has  to  be  administered, 
when  Trendelenburg's  position  is  more  suitable,  as  it  is  easier  to 
maintain  her  in  it.  An  anaesthetic  is  usually  necessary,  as  the 
introduction  of  the  hand  into  the  vagina  makes  the  patient  strain, 
and  straining  renders  reposition  impossible.  The  hand  is  intro- 
duced into  the  vagina,  with  the  fingers  in  the  shape  of  a  cone, 
and,  if  the  membranes  are  intact,  an  attempt  may  be  made  to 
replace  the  cord  without  rupturing  them.  To  do  this,  two  or 
three  fingers  are  passed  through  the  uterine  orifice  and  the  pre- 
senting part  is  pushed  upwards.  The  fingers  then  surround  the 
presenting  loop  of  cord  and  push  it  also  upwards,  together  with 
the  intervening  membranes,  until  it  is  past  the  greatest  convexity 
of  the  presenting  part.  If  this  process  succeeds,  the  membranes 
are  punctured  with  a  stylette  passed  along  the  fingers  which  are 
still  in  the  uterus,  and  the  liquor  amnii  is  allowed  to  escape  as 
slowly  as  possible.  The  fingers  are  then  gradually  withdrawn, 
the  other  hand  pushing  the  presenting  part  after  them  into  the 
brim.  If  this  manoeuvre  fails,  the  membranes  must  be  ruptured, 
and  the  prolapsed  loop  grasped  in  the  hand  and  carried  upwards 
above  the  presenting  part  as  before,  and  then  the  presenting  part 
pushed  down.  All  efforts  at  reposition  must  be  made  in  the 
interval  between  the  contractions.  If  manual  reposition  cannot 
be  effected,  instrumental  reposition  may  be  tried,  but  it  is  unlikely 
to  succeed.  If  it  also  fails,  the  only  treatment  that  offers  much 
prospect  of  success  is  immediate  delivery,  either  by  extraction 
as  a  pelvic  presentation  or  by  the  forceps. 

53—2 


336 


THE  PATHOLOGY  OF  LABOUR 


(3)  Instrumental  Reposition. — Reposition  by  mean's  of  any  of 
the  many  forms  of  repositor,  specially  manufactured  or  im- 
provised, is  a  very  difficult  process,  and  one  which  but  seldom 
succeeds.  For  its  performance,  the  same  conditions  must  be 
present  as  for  manual  reposition,  save  that  the  uterine  orifice 
need  not  be  so  widely  dilated,  as  it  ought  to  be  possible  to 
replace  the  cord  in  any  case  of  prolapse  through  an  orifice  which 
was  sufficiently  dilated  to  allow  the  prolapse  to  occur.  Many 
forms  of  specially  devised  repositors  have  been  made  from  time  to 
time,  but  none  of  them  has  proved  itself  anything  superior  to — if 
as  good  as — the  implements  that  can  be  improvised  from  a  gum- 
elastic  catheter.  The  most  suitable  implement  consists  of  a  new 
No.  10  or  12  gum-elastic  catheter  with  a  stout  stylette,  and  some 
common  white  tape  which  has  been  sterilised  by  boiling.     A.  piece 


Fig.  358. — Method  of  using  Catheter-repositor. 


of  tape  eight  inches  long  is  taken,  and  the  ends  knotted  together. 
A  loop  of  this  is  then  pushed  into  the  eye  of  the  catheter,  from 
which  the  stylette  has  first  been  partially  withdrawn,  and  the 
stylette  again  pushed  fully  into  its  place,  in  such  a  manner  as  to 
pass  through  the  loop  and  hold  it  in  the  eye.  The  remainder  of 
the  tape  is  then  passed  round  a  loop  of  the  cord,  as  shown  in 
Fig.  358,  and  its  end  pushed  over  the  top  of  the  catheter.  In  this 
way,  the  cord  is  attached  to  the  catheter  by  a  fastening  which 
will  not  open  so  long  as  the  catheter  is  being  pushed  upwards, 
but,  as  soon  as  the  catheter  is  withdrawn,  the  tape  will  again  slip 
over  the  top  of  the  catheter  and  set  the  cord  free.  As  soon  as  the 
tape  has  been  so  adjusted  as  to  snare  a  large  loop  of  the  cord,  the 
catheter  is  passed  into  the  uterus  beside  the  presenting  part 
and  is  pushed  upwards  as  far  as  it  will  go.  If  it  meets  with  an 
obstruction  before  it  has  penetrated  sufficiently  into  the  uterus,  it 


IMMEDIATE  DELIVERY  IN  PROLAPSE  OF  CORD  837 

is  slightly  withdrawn  and  pushed  up  in  a  different  direction.  If 
it  succeeds  in  carrying  the  cord  above  the  presenting  part,  the 
latter  is  pushed  down  into  the  brim  and  the  catheter  then  gently 
withdrawn.  Another  method  of  using  it  consists  in  tying  a  loop 
of  tape  loosely  round  a  coil  of  the  cord,  and  then  passing  an  end 
of  the  loop  into  the  eye  of  the  catheter  as  before.  The  catheter 
is  then  pushed  upwards,  and,  as  soon  as  the  cord  is  in  its  proper 
place,  the  loop  is  set  free  by  withdrawing  the  stylette,  and  the 
catheter  itself  is  drawn  down.  Instrumental  reposition  is  simple 
to  describe,  but  difficult  to  perform.  It  should,  however,  be  tried 
if  there  is  no  other  suitable  method  of  treating  the  case,  and 
sometimes  it  may  succeed. 

Podalic  Version. — Podalic  version  is  indicated  in  cases  of  pro- 
lapse of  the  cord  in  which  reposition  has  failed  or  is  impossible, 
and  in  which  the  degree  of  dilatation  of  the  uterine  orifice  is  not 
sufficient  to  permit  the  extraction  of  the  foetus  as  a  head  pre- 
sentation by  the  forceps.  The  usual  conditions  that  are  required 
for  the  performance  of  version  must  be  present,  i.e.,  the  pre- 
senting part  must  not  be  fixed,  and  the  uterine  orifice  must  be 
sufficiently  dilated  to  allow  the  introduction  of  two  fingers,  or — 
if  bipolar  version  is  impossible — of  the  whole  hand.  The  object 
of  performing  podalic  version,  in  cases  in  which  a  cephalic  pre- 
sentation is  associated  with  prolapse  of  the  cord,  is  to  substitute 
for  the  head  a  part  of  the  foetus  which  is  smaller  and  softer,  and 
so  to  lessen  the  compression  on  the  cord.  When  the  foetus  is 
turned  into  a  pelvic  presentation  and  a  foot  brought  down,  there 
is  usually  a  space  at  one  side  of  the  sacrum  of  the  mother  where 
the  cord  can  be  placed.  There  is  also  another  object  in  per- 
forming version,  that,  if  the  pulsations  of  the  cord  become  feeble, 
we  can  extract  the  foetus  at  any  moment  by  traction  upon  the 
leg.  In  performing  version,  the  foetus  should  be  turned  in  the 
reverse  direction  to  that  ordinarily  adopted.  Under  other  circum- 
stances, the  pelvis  is  brought  over  the  brim  by  the  shortest  route, 
i.e.,  the  head  is  pushed  in  the  direction  of  the  foetal  back,  and  the 
breech  in  the  opposite  direction.  This  procedure,  as  will  be 
readily  understood,  tends  at  one  stage  to  bring  the  umbilicus 
nearer  to  the  pelvic  brim  than  it  was  before,  and  so  to  favour  the 
descent  of  more  of  the  cord.  If,  however,  the  foetus  is  turned  the 
reverse  way,  i.e.,  if  the  head  is  pushed  in  the  direction  of  the  foetal 
chest,  and  the  breech  in  the  opposite  direction,  the  umbilicus  will 
be  carried  further  away  from  the  pelvic  brim  than  it  was  before. 
As  the  leg  is  brought  down  into  the  vagina,  the  prolapsed  loop 
of  cord  should  be  placed  at  the  sacral  end  of  the  oblique  diameter 
opposite  to  that  in  which  the  back  of  the  foetus  lies,  i.e.,  if  the 
bi-trochanteric  diameter  of  the  foetus  corresponds  to  the  right 
oblique  diameter  of  the  brim,  the  cord  should  be  placed  near  the 
left  sacro-iliac  joint. 

Immediate  Delivery. — Immediate  delivery  is  the  final  resource 
at   the  disposal  of  the  obstetrician  when  reposition  of  the  cord 


83S  THE  PATHOLOGY  OF  LABOUR 

has  failed  and  podalic  version  is  either  impossible  or  has  been 
performed  without  benefit.  In  the  case  of  a  head  presentation 
delivery  is  effected  by  the  forceps,  in  the  case  of  a  pelvic  presenta- 
tion by  traction  on  a  leg.  If  the  head  presents,  and  the  forceps 
is  to  be  applied,  the  uterine  orifice  must  be  sufficiently  dilated  to 
allow  the  passage  of  the  head  without  laceration.  If  it  is  not 
sufficiently  dilated,  and  if  the  head  is  fixed  and  so  version  is  im- 
possible, it  must  be  dilated  manually  or  incised.  There  is  no  time 
in  such  cases  for  the  use  of  hydrostatic  or  mechanical  dilators. 
Cases  of  this  kind,  in  which  the  head  is  fixed,  the  os  insufficiently 
dilated  to  apply  forceps,  and  the  foetus  still  alive,  are  rare,  but, 
when  they  do  occur,  they  are  most  difficult  to  treat.  Rapid 
extraction  with  the  forceps  is  unjustifiable,  as  it  exposes  the 
mother  to  too  great  risk.  Slow  extraction,  giving  the  orifice  time 
to  dilate,  is  useless,  as  the  foetus  will  be  dead  before  it  is  delivered. 
Manual  dilatation  rapidly  performed,  or  incision  in  cases  where 
the  edges  of  the  uterine  orifice  are  thin,  as  in  primiparae,  followed 
by  the  application  of  the  forceps,  is  the  only  treatment  which  can 
be  adopted.  Once  traction  with  the  forceps  has  been  commenced, 
it  must  be  rapid,  as  the  cord  is  compressed  during  the  entire 
time  the  head  is  passing  through  the  pelvis,  and,  if  this  com- 
pression is  continued  for  more  than  two  or  three  minutes,  the 
foetus  will  be  born  dead.  In  applying  the  forceps,  care  must  be 
taken  not  to  include  a  loop  of  the  cord  between  the  blade  and  the 
head  of  the  foetus. 

Extraction  in  the  case  of  a  pelvic  presentation  calls  for  little 
special  comment.  It  should  not  be  commenced  until  it  is  neces- 
sary, as  shown  by  weakness  or  cessation  of  the  contractions  of 
the  cord,  as  it  is  always  difficult  to  extract  a  foetus  quickly 
through  an  imperfectly  dilated  os,  and,  if  the  process  is  slow,  the 
death  of  the  foetus  may  result.  There  is  also  a  risk  of  cervical 
laceration.  If,  however,  the  pulsations  of  the  cord  show  that 
compression  is  occurring,  extraction  must  be  performed  as  slowly 
and  carefully  as  is  consistent  with  the  safety  of  the  foetus.  In 
a  pelvic  presentation,  however,  compression  of  the  cord,  as  a 
rule,  will  not  occur  until  the  breech  has  descended  into  the  pelvis, 
and  at  that  stage  the  os  will  be  nearly  or  quite  fully  dilated. 

The  treatment  of  presentation  and  prolapse  may  be  summed 
up  in  a  few  words.  In  all  cases,  first  think  of  the  possibility  of 
performing  reposition.  If  the  membranes  are  intact,  this  may  be 
done  by  the  postural  method,  or,  failing  this,  by  the  manual  or 
instrumental  method  ;  if  the  membranes  are  ruptured,  the  manual 
or  instrumental  method  will  alone  succeed.  If  reposition  by  any 
method  is  impossible,  and  the  head  presents  but  is  not  fixed,  per- 
form podalic  version  and  draw  down  a  foot.  So  long  as  the 
pulsations  of  the  cord  show  that  there  is  no  compression,  leave 
delivery  to  the  natural  efforts,  but,  if  compression  occurs,  extract 
at  once.  If  podalic  version  is  impossible,  and  if  the  uterine 
orifice  is  sufficiently  dilated,  extract  the  foetus  with  the  forceps. 
If  the  orifice  is  not  sufficiently  dilated,  dilate  it  manually  or  incise 


PROGNOSIS  IN  PROLAPSE  OF  CORD 


839 


it.  Occasionally,  a  case  may  occur  where  the  condition  may  be 
left  untreated,  even  though  the  foetus  is  alive.  If  the  patient  has 
had  many  children,  and  if  the  genital  passages  are  roomy,  the 
fcetus  small,  and  the  uterine  contractions  strong,  delivery  may 
be  left  to  the  natural  efforts,  as  the  second  stage  will  probably 
be  of  very  short  duration  and  can  be  further  shortened  by 
pressure  on  the  fundus.  The  obstetrician  must,  however,  watch 
the  case  most  closely,  and  be  ready  to  apply  the  forceps  the 
moment  any  signs  of  delay  or  of  compression  occur. 

Prognosis. — The  maternal  prognosis  in  cases  of  presentation 
and  prolapse  of  the  cord  is  not  materially  affected,  save  so  far  as 
the  operative  procedures  undertaken  to  save  the  fcetus  may  prove 
prejudicial,  either  by  causing  laceration  of  the  soft  parts  or  septic 
infection.  The  foetal  prognosis  is,  however,  directly  made  more 
serious.  The  aggregated  statistics  of  several  continental  clinics 
show  that  out  of  1,376  cases  of  presentation  or  prolapse,  657  infants 
were  born  dead,  or  a  percentage  mortality  of  about  fifty.  The 
following  table  shows  the  results  obtained  by  the  different  modes 
of  treatment  in  about  400  cases  of  presentation  and  prolapse 
(Massmann*)  : — 


i 

Original  Presenta-                 Treatment. 

Percentage. 

Lived.                Died. 

Vertex         -         -         -     Left  to  nature 

, ,               ...     Forceps 

-         -         -     Version  and  extraction  - 
Pelvic           -         -         -  1  Left  to  nature 

,,               -         -         -  1  Extracted 
Shoulder     -         -         -     Version  and  extraction  - 
Various  presentations      Reposition 

34                      66 
61                      39 
46                      54 
50                      50 
58                      42 

49                      51 
71-72                29-28 

A  table  constructed  on  somewhat  similar  lines  from  the  reports 
of  the  Rotunda  Hospital  gives  the  following  results  : — 


Treatment  adopted. 

Presentation. 

NO.    OF 

Cases. 

Vertex. 

Pelvic.         Face.     |    Shoulder. 

Left  to  nature 
Forceps 

Version  and  extraction  - 
Reposition 
Extraction  alone     - 
Infants  born  alive  - 
,,     dead  - 

22 
25 
15 

5 

~~ 
33 

34 

18                 1 

18               — 
22                 1 
14 

10 

1 

7 
4 

41 
25 
25 
6 
18 

63 

52t 

*  Petersburger  Med.  Zeitsch.,  xiv. ,  Nos.  3,  4,  1868. 

\   Of  these  infants,  21  were  dead  before  the  cases  came  under  treatment. 


CHAPTER   VIII 
ANOMALIES  OF  FOZTAL  DEVELOPMENT 

Excessive  Size  of  the  Normally  Shaped  Foetus — Of  the  Entire  Foetus 
— Of  the  Shoulders.  Excessive  Size  of  the  Foetus  due  to  Disease — 
Hydrocephalus — Hydromeningocele,  Hydrencephalocele,  Encephalocele 
— General  Foetal  GZdema,  Hydrothorax,  Ascites — Abnormalities  of  the 
Urinary  Organs — Spina  Bifida — Sacro-coccygeal  Tumours — Cystic  and 
Solid  Tumours  of  the  Neck — Tumours  of  the  Liver  and  Spleen.  Monsters 
— Single  Monsters— Double  Monsters. 


EXCESSIVE  SIZE  OF  THE  NORMALLY  SHAPED 

FCETUS 

A  normally  shaped  foetus  may  give  rise  to  difficult  labour 
owing  to  its  excessive  size  as  a  whole,  or  to  the  excessive  size  of 
the  shoulders. 

Excessive  Size  of  the  Entire  Fcetus. — The  foetus  may 
sometimes  reach  so  great  a  size  in  utevo  that  its  passage  through 
the  pelvis  is  a  matter  of  difficulty  or  impossibility.  It  is  im- 
possible to  fix  any  limit  above  which  a  fcetus  is  too  large  to  be 
expelled  naturally,  and  below  which  it  can  be  so  expelled,  as  so 
much  depends  upon  the  size  of  the  pelvis,  the  powers  of  the 
mother,  and  the  size  and  ossification  of  the  foetal  head,  but, 
speaking  generally,  any  fcetus  which  exceeds  eleven  pounds  in 
weight  is  likely  to  cause  a  difficult  labour. 

We  have  already  discussed  the  various  factors  which  tend  to 
influence  the  weight  of  the  foetus,  and  need  not  again  refer  to 
them  (v.  p.  1 08). 

Diagnosis. — It  is  usually  impossible  to  determine  the  presence 
of  an  abnormally  large  fcetus  until  delay  in  labour  leads  us  to 
pass  the  hand  into  the  uterus.  It  is  true  that,  with  the  possession 
of  sufficient  skill,  we  ought  to  be  able  to  ascertain  by  abdominal 
palpation  that  a  foetus  is  above  the  normal  size,  but  in  practice 
there  are  so  many  obstacles,  such  as  the  thickness  of  the  abdo- 
minal walls,  and  the  amount  of  liquor  amnii,  that  it  is  extremely 
difficult  to  do  so  with  any  certainty.  As  a  rule,  in  these  cases, 
the  presence  of  a  large  foetus  is  not  suspected  by  the  obstetrician, 

840 


EXCESSIVE  SIZE  OF  THE  SHOULDERS  841 

if  the  foetal  head  has  passed  into  the  pelvic  cavity.  The  forceps 
is  applied  on  account  of  the  delay  in  labour,  and  if  the  foetus 
cannot  be  extracted  in  this  manner,  perforation  is  usually  per- 
formed, and  then,  after  extraction,  the  cause  of  the  delay  is 
recognised.  It  is  difficult  to  say  how  an  earlier  diagnosis  can  be 
arrived  at  in  such  cases.  An  obstetrician  of  considerable  ex- 
perience might,  it  is  true,  be  able  to  determine  that  he  was 
dealing  with  a  large  foetus  by  noticing  that  the  distance  between 
the  fontanelles  was  greater  than  usual,  but  this  is  difficult  and  we 
must  usually  be  satisfied  with  a  post-partum  diagnosis.  When, 
however,  the  size  of  the  foetus  is  so  great  that  the  head  cannot 
pass  into  the  pelvic  cavity,  it  is  easier  to  arrive  at  a  diagnosis. 
The  first  thing  that  is  suggested  by  the  detention  of  the  head 
above  the  brim  is  a  contracted  pelvis,  and  if  the  history  of  the 
patient,  and  the  measurement  of  the  pelvis,  shows  that  such  is  not 
the  case,  the  next  thing  to  be  thought  of  is  an  unusually  large 
head.  Then,  on  passing  the  hand  into  the  uterus  and  examining 
the  head,  we  shall  be  able  to  detect  the  existence  of  such  a 
condition.  Uniform  .enlargement  of  the  head,  the  result  of  the 
excessive  size  of  the  foetus,  can  be  distinguished  from  enlargement 
due  to  some  pathological  cause  by  the  fact  that  the  head  pre- 
serves its  normal  configuration. 

Treatment. — The  treatment  of  cases  of  an  unusually  large  foetus 
calls  for  the  exercise  of  considerable  skill,  if  the  foetus  is  to  be 
given  the  best  prospect  of  life.  If  the  foetal  head  has  passed  the 
brim,  delivery  can  usually  be  accomplished  by  the  forceps.  If 
the  head  is  above  the  brim,  the  most  suitable  treatment  to  adopt 
depends  upon  the  degree  of  disproportion  present.  If  the  dis- 
proportion is  considerable,  it  may  be  that  symphysiotomy  offers 
the  best  chance,  but,  as  this  is  a  serious  operation,  the  obstetrician 
naturally  hesitates  to  adopt  it,  unless  he  is  sure  that  delivery  is 
not  possible  by  any  other  means,  and  unless  the  surroundings  are 
suitable  for  the  performance  of  the  operation.  There  is  no  doubt, 
however,  that  in  many  cases  symphysiotomy  offers  the  only 
chance  of  saving  the  foetus.  If  the  disproportion  is  not  so  con- 
siderable as  to  necessitate  symphysiotomy,  the  performance  of 
podalic  version,  and  the  extraction  of  the  foetus  with  the  patient 
in  Walcher's  position  may  be  successful.  While,  if  the  dispro- 
portion is  but  slight,  and  the  non-descent  of  the  head  is  due  more 
to  the  weakness  of  the  contractions  than  to  the  size  of  the  head, 
extraction  by  the  forceps  may  be  possible.  If  the  foetus  is  dead 
and  forceps  extraction  impossible,  craniotomy  must  be  performed. 

It  sometimes  happens  that,  even  after  the  head  has  been 
successfully  delivered,  the  shoulders  cannot  be  brought  through. 
Such  cases  will  be  discussed  in  the  next  paragraph. 

Excessive  Size  of  the  Shoulders. — Excessive  size  of  the 
shoulders  of  the  foetus  may  be  met  with  as  part  of  a  general 
foetal  enlargement,  or  as  an  enlargement  confined  to  the  shoulders 


842  THE  PATHOLOGY  OF  LABOUR 

alone.  In  both  cases,  the  result  is  the  same,  the  shoulders  become 
impacted  either  at  the  pelvic  brim  or  in  the  cavity,  and  the 
further  advance  of  the  fcetus  is  prevented. 

Diagnosis. — The  diagnosis  of  impaction  of  the  shoulders  is  made 
when  the  head  or  the  breech  of  the  fetus  is  delivered  either 
naturally  or  artificially,  and  the  shoulders  do  not  follow  in  the 


Fig.  359. — Impacted  Shoulders. 
The  usual  position  of  the  shoulders  when  impacted  in  the  pelvis. 

usual  manner.  This  impaction  may  be  due  to  the  excessive  size 
of  the  shoulders,  or  to  the  failure  of  normally  sized  shoulders  to 
rotate. 

Treatment. — If  the  head  of  the  foetus  is  expelled,  but  the  shoulders 
do  not  follow  it,  the  first  step  to  be  adopted,  with  the  object 
of  expediting  their  delivery,  consists  in  applying  firm  pressure  to 


HYDROCEPHALUS  843 

the  fundus.  If  this  is  not  sufficient,  it  is  supplemented  by  traction 
upon  the  head.  If  this  also  fails,  the  fingers  are  passed  into  the 
vagina  and  hooked  into  the  anterior  axilla,  which  lies  lower  than 
the  posterior.  Downward  traction  is  then  made  with  these 
fingers,  and,  as  soon  as  the  shoulders  have  reached  the  pelvic 
floor,  the  axilla  is  guided  forward  beneath  the  arch  of  the  pubis. 
If  the  shoulders  will  not  descend,  the  fingers  may  be  passed  into 
the  axilla  which  lies  posteriorly,  and  traction  made  alternately 
upon  the  two.  When  the  shoulders  have  been  brought  down 
as  far  as  the  pelvic  outlet,  it  is  possible  to  make  traction  on 
both  simultaneously.  If  they  do  not  respond  to  such  forms  of 
traction,  the  next  step  consists  in  bringing  down  one  or  both 
arms.  This  is  done  with  the  double  object  of  diminishing  the 
width  of  the  shoulders  by  the  thickness  of  each  arm  as  it  is 
brought  down,  and  of  giving  an  additional  means  of  making 
traction  on  the  body.  If  the  arms  can  be  brought  down,  it  is 
probable  that  it  will  be  always  possible  to  extract  the  shoulders 
without  any  cutting  operation ;  but,  in  cases  in  which  the  shoulders 
are  firmly  impacted  in  the  pelvic  cavity,  it  will  not  be  possible 
to  bring  them  down.  In  such  cases,  delivery  without  a  cutting 
operation  is  usually  impossible.  If  the  arms  cannot  be  brought 
down,  or  if,  even  after  they  have  been  brought  down,  delivery  is 
still  impossible,  the  next  step  consists  in  performing  the  operation 
of  cleidotomy  or  division  of  the  clavicles.  This  operation  is  said 
to  effect  a  reduction  in  the  length  of  the  shoulder  girdle  of  three 
to  four  centimetres,  and  to  be  not  incompatible  with  the  continued 
life  of  the  foetus.  If  the  shoulders  still  will  not  descend,  it  is 
probable  that  there  is  some  pathological  enlargement  of  the 
thorax,  and  that  the  only  course  to  adopt  consists  in  performing 
embryotomy. 


EXCESSIVE    SIZE    OF    THE    FCETUS    DUE    TO 
DISEASE 

Hydrocephalus. — Hydrocephalus  is  the  term  applied  to  an 
abnormally  large  accumulation  of  cerebro-spinal  fluid  within  the 
cranium.  This  fluid  collects  first  in  the  ventricles,  which  it 
distends  greatly.  In  some  cases,  it  may  remain  confined  there, 
but  in  others  it  bursts  its  way  through  the  surrounding  brain 
substance,  and  is  found  in  the  sub-arachnoid  space,  or  between 
the  arachnoid  and  the  dura  mater.  The  average  amount  of 
fluid  that  collects  is  about  one  to  two  litres  (if  to  3^  pints), 
but  as  much  as  ten  to  twelve  litres  (17  to  20  pints)  have  been 
found  in  extreme  cases  (Ribemont-Dessaignes).  The  effect  upon 
the  brain  of  the  accumulation  of  fluid  is  very  marked.  If  the 
fluid  remains  in  the  ventricles,  the  brain  substance  is  converted 
into  a  structure  resembling  the  wall  of  a  cyst,  while,  if  the  fluid 
finds   its    way  through   the   brain   to    the   meninges,    the   brain 


844  THE  PATHOLOGY  OF  LABOUR 

substance  is  compressed  and  flattened  out  against  the  cranial 
bones. 

The  effect  upon  the  bones  of  the  vault  of  the  skull  is  also  very 
marked.  The  bones  are  widely  separated  from  one  another, 
they  are  considerably  thinner  than  is  usual,  and  the  sutures  are 
enormously  increased  in  size.  The  bones  of  the  base  of  the 
skull  and  of  the  face  are  not  affected  by  this  change,  and  thus 
the  characteristic  hydrocephalic  appearance  of  an  enormous 
cranial  vault  overhanging  a  diminutive  face  is  produced. 

The  causes  of  congenital  hydrocephalus  are  very  far  from  being 
determined.  It  sometimes  occurs  when  the  parents  are  syphilitic 
or  alcoholic,  and  not  uncommonly  is  found  in  association  with 
other  pathological  conditions  of  the  foetus,  such  as  spina  bifida, 
hydramnios,  hydrothorax,  and  club-foot.  Ballantyne*  speculates 
on  its  aetiology,  but  admits  that  little  or  nothing  is  known  of  it. 

Frequency. —  Hydrocephalus  is  a  rare  complication,  and  is  said 
to  occur  once  in  every  1,000  to  2,000  labours. 

Diagnosis.  —  The  diagnosis  of  hydrocephalus,  in  which  the 
cranial  enlargement  is  considerable,  can,  as  a  rule,  be  made  by 
abdominal  palpation,  by  noting  the  size  and  consistency  of  the 
head.  If  the  head  presents,  the  diagnosis  can  be  readily  confirmed 
by  vaginal  examination  after  labour  has  commenced,  by  noting 
the  separation  of  the  cranial  bones,  the  bulging  of  the  sutures, 
and  the  increased  size  of  the  head,  as  shown  by  the  fact  that 
it  does  not  descend  into  the  pelvis.  When  there  is  a  large 
accumulation  of  fluid,  and  considerable  separation  of  the  cranial 
bones,  we  may  be  unable  to  feel  the  latter  by  vaginal  examination, 
and  only  find  a  large  cystic  tumour  presenting  inside  the  uterine 
orifice.  It  has  not  infrequently  happened  that,  under  such  cir- 
cumstances, a  hydrocephalic  head  has  been  mistaken  for  an 
unruptured  bag  of  membranes,  and  attempts  made  to  rupture 
it  with  the  finger-nail  or  stylette.  Such  a  mistake  may  be 
avoided  by  noting  the  presence  of  hair  and  the  unusual  thickness 
of  the  supposed  membranes.  When  the  pelvic  pole  of  the  foetus 
presents,  we  must  rely  on  abdominal  palpation  altogether  until 
the  body  of  the  foetus  has  been  born,  and  we  are  able  to  reach 
the  head  with  the  hand  passed  into  the  uterus. 

Effect  upon  Labour. — The  effect  of  hydrocephalus  upon  labour 
is  similar  to  that  of  any  other  obstacle  which  prevents  the 
descent  of  the  head  into  the  pelvis.  The  uterus  makes  violent 
efforts  to  expel  the  foetus,  and,  failing  to  do  so,  a  condition  of 
secondary  uterine  inertia  supervenes,  or  rupture  of  the  uterus 
results.  In  very  rare  cases,  the  strength  of  the  contractions  may 
be  sufficient  to  force  the  fluid  through  the  thinned  sutures  outside 
the  cranium.  It  then  makes  its  way  through  the  cellular  tissue 
of  the  scalp  downwards  towards  the  neck.  In  this  manner, 
sufficient  diminution  in  the  size  of  the  cranium  may  result  to 
allow  the  latter  to  collapse,  and  so  to  enable  delivery  to  occur. 
*  'Ante-natal  Pathology  and  Hygiene,'  vol.  i.,  p.  389. 


HYDROMENINGOCELE,  AND  HYDRENCEPHALOCELE        845 

The  greater  the  amount  of  fluid  present,  the  more  likely  is  the 
intracellular  effusion  of  fluid  to  occur,  as  the  thinner  will  be  the 
interosseous  membrane.  The  obstetrician  must  not,  however, 
trust  to  the  possibility  of  such  an  occurrence,  as  it  is  one  of 
extreme  rarity. 

Treatment. — The  treatment  of  hydrocephalus  is  obvious.  The 
fluid  must  be  allowed  to  escape,  and  then,  if  the  uterine  con- 
tractions do  not  rapidly  expel  the  foetus,  it  must  be  extracted. 
The  ideal  operation  consists  in  tapping  the  head  with  a  trochar 
and  canula,  as  this  affords  some  slight  prospect  of  delivering  the 
foetus  alive.  If  the  necessary  instruments  are  to  hand,  such  a 
course  may  be  adopted;  but,  even  if  the  foetus  is  delivered  alive, 
it  will  rarely  survive  its  birth  for  long,  and,  in  the  few  cases  in 
which  it  does  so,  will  probably  exhibit  some  mental  deficiency. 
Consequently,  the  usual  treatment  to  adopt  consists  in  perforating 
the  head  and  then  extracting  it  with  a  cranioclast.  Perforation 
is  also  adopted  in  the  case  of  the  after-coming  hydrocephalic  head, 
but,  if  the  distension  is  very  great,  and  if  it  is  difficult  to  bring 
the  head  within  reach  of  the  perforator,  the  spinal  canal  may  be 
opened,  a  catheter  passed  into  it  and  pushed  upwards  into  the 
cranium.  By  moving  the  catheter  about,  the  accumulation  of 
fluid  will  be  tapped,  and  will  escape  through  the  catheter.  The 
application  of  the  cranioclast  to  the  after-coming  head  is  usually 
unnecessary,  as  the  head  can  be  delivered  by  Smellie's  or 
Martin's  method. 

Prognosis. — The  prognosis  for  the  foetus  is  almost  absolutely 
bad  in  hydrocephalus.  Even  when  it  is  born  alive,  it  rarely 
survives  more  than  a  few  hours.  In  a  small  proportion  of  cases, 
it  may  live  for  a  few  months,  or  possibly  longer.  The  maternal 
prognosis  depends  upon  the  period  of  labour  at  which  the  condi- 
tion is  recognised.  If  it  is  detected  in  time,  the  treatment  of  the 
case  is  easy  and  the  prognosis  should  not  be  more  grave  than  in 
normal  labour.  If,  however,  the  condition  is  not  recognised,  and 
the  patient  is  allowed  to  remain  undelivered,  or  if  useless  attempts 
at  extraction  are  made  with  the  forceps,  the  prognosis  becomes 
more  serious,  as  rupture  of  the  uterus  or  serious  lacerations  of 
the  maternal  soft  parts  may  result.  It  is  well  known  that,  in 
hydrocephalus,  the  maternal  prognosis  is  better  in  the  case  of 
large  accumulations  of  fluid  than  in  the  case  of  small  accumula- 
tions, as  the  former  are  recognised  at  once,  whilst  the  latter  often 
escape  recognition. 

Hydromeningocele,and  Hydrencephalocele  or  Encephalo- 
cele. — A  hydromeningocele  is  the  term  applied  to  a  cystic 
tumour  on  the  outside  of  the  cranium  formed  by  the  extrusion 
through  a  cleft  in  the  cranial  bones  of  a  portion  of  the  meninges 
filled  with  fluid.  It  is  the  result  of  the  association  of  a  sub- 
arachnoid accumulation  of  fluid  and  a  cleft  in  the  cranial  bones. 
Hydrencephalocele    or    encephalocele    is   a   rarer    condition,    in 


846  THE  PATHOLOGY  OF  LABOUR 

which  a  tumour  containing  fluid  and  brain  substance  forms  on 
the  outside  of  the  cranium.  It  is  the  result  of  the  association 
of  an  accumulation  of  fluid  in  the  ventricles  and  a  cleft  in  the 
cranial  bones.  The  tumour  is  usually  of  ovoid  form  and  is  con- 
nected with  the  cranium  by  a  pedicle  of  varying  size.  There 
may  or  may  not  be  free  communication  between  the  tumour  and 
the  cranial  cavity.  Such  tumours  are  most  commonly  found  in 
the  occipital  region,  and  also  in  the  frontal.  They  may,  however, 
occur  at  any  point  in  the  cranial  vault.     Winckel  classifies  them, 


Fig.  360. — A  Fcetus  with  Hydromeningocele  and  Congenital  Absence 
of  Abdominal  Wall. 

M,  Hydromeningocele.     (From  a  specimen  in  the  School  of  Physic, 
Trinity  College,  Dublin.) 


according  to  their  situation,  as  anterior,  posterior,  lateral,  superior, 
or  inferior. 

Treatment. — Such  tumours,  if  small,  do  not,  as  a  rule,  give  rise 
to  any  difficulty  during  delivery.  If  they  are  of  large  size,  they 
must  be  punctured  and  the  fluid  allowed  to  escape.  The  fcetus 
can  then  be  delivered  by  the  forceps  or  delivery  left  to  the  natural 
efforts. 


FCETAL  (EDEMA,  HYDROTHORAX,  ASCITES  S47 

General  Fcetal  CEdema,  Hydrothorax,  Ascites.— General 
foetal  cedema  sometimes  gives  rise  to  difficult  labour,  owing  to  the 
increase  which  it  causes  in  the  size  of  the  foetus.  Sometimes, 
this  increase  is  uniform  and  is  due  to  a  general  dropsical  condition 
of  the  foetal  skin,  while,  at  other  times,  it  is  due  to  an  accompany- 
ing accumulation  of  fluid  in  the  thoracic  or  peritoneal  cavity. 
The  weight  and  dimensions  of  the  foetus  are  always  increased. 
The  causes  of  fcetal  dropsy,  like  the  causes  of  hydrocephalus, 
are  as  yet  undetermined.  Ballantyne*  suggests  that  it  may  arise 
in  the  later  months  of  pregnancy  from  maternal  conditions  which 
increase  the  blood  -  pressure  in  the  placenta,  thus  leading  to 
increased  pressure  in  the  foetal  vessels  and  transudation  of 
serum  in  the  foetal  body.  He  also  suggests  that  structural 
alterations  may  occur  in  the  fcetal  heart,  kidneys,  liver,  or  blood, 
and  directly  produce  increased  blood-pressure  as  in  the  adult. 

Hydrothorax — a  collection  of  fluid  in  the  thoracic  cavity — 
may  occur  in  association  with  general  cedema,  or  as  a  distinct 
condition.  It  may  cause  very  considerable  enlargement  of  the 
chest.     Its  pathology  is  obscure. 

Ascites  is  a  more  common  condition,  and  may  occur  in  associa- 
tion with,  or  distinct  from,  general  cedema.  It  may  lead  to  an 
enormous  increase  in  the  size  of  the  abdomen.  The  average 
amount  of  fluid  is  from  two  to  four  litres  (3^  to  7  pints),  but  as 
much  as  twelve  to  fifteen  litres  have  been  found.  The  aetiology 
of  foetal  ascites  is  not  clearly  established.  It  occurs  in  foetal  syphilis, 
when  it  is  probably  due  to  changes  in  the  liver.  It  may  also  occur 
as  a  result  of  pressure  on  the  portal  vein — as  in  a  case  recorded 
by  Herman.!  According  to  Ballantyne,]:  it  is  most  frequently  the 
result  of  peritonitis.  The  cause  of  peritonitis  in  such  cases  is 
obscure,  but  in  one  case  it  was  found  to  be  an  escape  of  urine 
into  the  peritoneal  cavity. 

Effect  upon  Labour. — The  effect  of  these  different  conditions 
upon  labour  is  to  cause  a  degree  of  obstruction  which  varies  in 
proportion  to  the  increase  in  size  of  the  foetus.  In  some  cases, 
labour  may  be  merely  delayed,  but,  in  others,  the  further  advance 
of  the  foetus  becomes  impossible,  and  secondary  uterine  inertia 
or  rupture  of  the  uterus  results. 

Diagnosis. — The  diagnosis  of  general  foetal  oedema  can  only  be 
made  by  vaginal  examination  or  by  passing  the  hand  into  the 
uterus  and  examining  the  foetus.  If  the  oedema  affects  the  scalp, 
the  condition  ought  to  be  recognised  on  vaginal  examination. 
The  diagnosis  of  hydrothorax  and  ascites  can  only  be  made  in 
the  latter  manner,  save  in  cases  where  there  is  an  enormous 
accumulation  of  fluid,  when  a  diagnosis  may  be  made  by  abdominal 
palpation.  As  a  rule,  however,  the  existence  of  such  conditions 
will  not  be  recognised  until  after  the  birth  of  the  presenting  part, 

*  Op.  cit.,  p.  296.  t  Med.  Times  and  Gazette,  pt.  ii.,  731,  1S81. 

%  Op.  cit.,  p.  361. 


848  THE  PATHOLOGY  OF  LABOUR 

when  the  size  of  the  thorax  or  abdomen  will  delay  or  prevent  the 
further  descent  of  the  fcetus. 

Treatment. — If  the  expulsion  of  the  foetus  is  prevented  by  a 
condition  of  general  oedema,  the  first  step  consists  in  evacuating 
all  cavities  in  which  fluid  may  be  contained.  Accordingly,  if  the 
head  is  increased  in  size  in  consequence  of  hydrocephalus,  it 
must  be  perforated,  and  the  thorax  and  peritoneal  cavity  in  turn 
similarly  treated,  as  they  are  brought  within  reach.  If  the 
increase  in  size  of  the  fcetus  is  due  to  a  general  waterlogging  of 
the  tissues,  craniotomy  followed  by  embryotomy  may  have  to  be 
performed.  In  hydrothorax  or  ascites,  the  affected  cavity  should 
be  tapped  with  a  trochar  and  canula  and  the  fluid  evacuated, 
and  embryotomy  is  only  necessary  when  the  accumulation  of  fluid 
is  associated  with  a  tumour  or  enlarged  viscus. 

Prognosis. — The  maternal  prognosis  is  similar  to  that  of  hydro- 
cephalus, and  depends  upon  the  early  recognition  of  the  condition. 
The  foetal  prognosis  is  absolutely  bad,  although  a  case  has  been 
recorded  in  which  the  infant  survived  after  the  abdomen  had  been 
tapped  and  a  quantity  of  fluid  evacuated. 

Abnormalities  of  the  Urinary  Organs. — Hydronephrosis 
is  sometimes  met  with  in  consequence  of  obliteration  of  the  ureter, 
and  the  distended  kidney  may  reach  a  large  size.  Cystic  degenera- 
tion of  one  or  both  kidneys  is  also  met  with,  in  which  the  kidney 
becomes  greatly  enlarged  and  converted  into  a  mass  of  small 
cysts.  This  condition  is  said  to  be  due  to  a  sclerosis  of  the 
uriniferous  tubules,  especially  in  the  neighbourhood  of  the  papillae. 
More  recent  researches,  however,  tend  to  show,  according  to 
Ballantyne,  that  it  is  of  the  nature  of  an  adenomatous  degenera- 
tion. 

Retention  of  urine  in  the  bladder  may  also  result  in  the  forma- 
tion of  a  large  abdominal  tumour.  As  much  as  two  and  a  half 
litres  of  fluid  have  been  found  (Fabris*),  while,  in  the  case 
recorded  by  Schwyzer,  t  the  fluid  was  said  to  amount  to  6^  litres. 
The  cause  of  the  retention  is  found  in  obliteration  or  kinking 
of  the  urethra.  It  is  obvious,  however,  that  in  the  case  of  a 
large  accumulation  there  must  be  also  some  pathological  con- 
dition present  capable  of  causing  an  abnormal  increase  in  the 
amount  of  urine  secreted  by  the  kidneys. 

Cystic  conditions  of  the  kidney  or  bladder  are  usually  diagnosed 
before  delivery  as  ascites,  and  are  treated  accordingly.  It  is  only 
on  subsequently  opening  the  abdomen  of  the  foetus  that  the  true 
cause  of  the  enlargement  is  discovered. 

Spina  Bifida. — Spina  bifida  is  the  term  applied  to  a  cystic 
tumour  found  on  the  back,  usually  over  the  lumbo-sacral  or 
dorsal  region  of  the  spinal  column,  and  which  is  formed  by  the 

*  Ann.  diostet.,  xvii.,  p.  329,  1895. 
I  Arch.  f.  Gynah.,  xliii.,  333,  1893. 


MONSTERS,  PROPERLY  SO  CALLED  849 

protrusion  of  the  spinal  meninges  through  a  fissure  in  the  spinal 
column,  the  result  of  imperfect  development.  It  contains  a 
varying  amount  of  cerebro-spinal  fluid,  and  may  reach  the  size 
of  a  foetal  head. 

Spina  bifida  rarely  reaches  such  a  size  as  to  offer  an  obstacle 
to  delivery.  If  it  does,  it  will  retard  or  prevent  the  descent  of 
the  back.  Its  existence  will  then  be  ascertained  by  passing  the 
hand  upwards  along  the  back  or  limbs  of  the  foetus,  as  the  case 
may  be.  In  such  cases,  it  must  be  punctured  and  the  fluid 
allowed  to  escape. 

Sacro  -  coccygeal  Tumours.  —  Solid,  semi  -  solid,  or  cystic 
tumours  are  sometimes  met  with  attached  to  the  sacro-coccygeal 
region  of  the  foetus.  These  tumours  are  of  three  different  classes. 
One  class  is  due  to  the  inclusion  of  portions  of  a  second  foetus — a 
teratoma.  A  second  class  is  cystic  and  communicates  with  the 
spinal  canal,  and  so  is  akin  to  a  spina  bifida.  A  third  class  is 
cystic  or  solid  in  character,  and  may  resemble  in  structure  many 
of  the  simple  and  malignant  tumours  of  adult  life.  All  classes  of 
tumour  vary  greatly  in  size.  If  they  are  so  large  as  to  obstruct 
delivery,  they  must  be  removed,  but,  as  a  rule,  they  are  soft  and 
pliable,  and  do  not  give  rise  to  any  difficulty  during  delivery. 

Cystic  and  Solid  Tumours  of  the  Neck. — Different  forms 
of  cystic  enlargement  are  occasionally  met  with  in  the  region  of 
the  neck.  Cystic  hygroma  is  the  term  applied  to  a  tumour  which 
originates  in  degenerated  lymphatic  vessels.  It  may  be  situated 
in  front  of  or  on  the  nape  of  the  neck,  and  sometimes  reaches  the 
size  of  a  foetal  head.  Cystic  enlargement  of  the  thyroid  gland 
also  occurs,  and  may  attain  a  large  size.  Congenital  enlarge- 
ments of  the  thyroid  are,  however,  as  a  rule  solid  (Winckel). 
They  are  sometimes  hyperplastic,  and  sometimes  fibrous  or 
cartilaginous.     They  may  attain  a  large  size. 

These  conditions,  as  a  rule,  do  not  offer  an  obstruction  to 
delivery,  as  they  are  soft  and  easily  moulded.  If  they  prevent 
the  passage  of  the  head,  they  must  be  tapped  or  removed  piece- 
meal, according  as  they  are  cystic  or  solid. 

Tumours  of  the  Liver  and  Spleen. — Such  tumours  occa- 
sionally occur  of  sufficient  size  to  obstruct  delivery.  In  such 
cases,  they  must  be  removed  by  embryotomy. 


MONSTERS,  PROPERLY  SO  CALLED 

Under  this  heading,  we  propose  to  discuss  such  of  the  recog- 
nised forms  of  atypical  development  as  affect  the  course  of  labour. 
We  do  not  propose  to  enter  into  a  description  of  all  the  various 
forms  of  malformations,  as  to  do  so  would  be  out  of  place  in  a 

54 


850  THE  PATHOLOGY  OF  LABOUR 

work  on  obstetrics.  It  will,  however,  be  necessary  to  give  a 
brief  description  of  them,  and,  in  this,  we  shall  follow  the  classifi- 
cation adopted  by  Geoffroy  Saint- Hilaire.*  In  this  classification, 
for  the  sake  of  convenience  of  description,  the  terms  '  class,'  'order,' 
'  family,'  '  genus,'  '  species,'  and  '  variety,'  are  used  as  if  such  a 
terminology  was  permissible. 

Monsters  are  divided  into  two  great  classes- — single  monsters 
and  double  monsters. 

Single  Monsters. 

Single  monsters  are  those  which  possess  the  elements — com- 
plete or  incomplete — of  a  single  individual.  This  class  is  divided 
into  three  orders  : — 

(A)  Omphalosites  (o/xc/>aA6s,  the  navel ;  o-iYos,  food),  in  which  the 
most  essential  organs  are  wanting,  and  which  consequently  only 
develop  passively  by  a  connection  through  the  umbilical  cord 
with  the  circulatory  apparatus  of  a  twin. 

This  order  is  divided  into  three  families  as  follows  : — 

(1)  Paracephalians  (irapd,  beside  ;  Ke^a.A.77,  the  head),  in  which 
there  is  a  rudimentary  head  formation,  general  asymmetry,  and 
absence  of  limbs  and  various  organs. 

(2)  Acephalians  (a,  negative;  Ke^aX-q),  in  which  there  is  com- 
plete absence  of  the  head  {v.  Fig.  361). 

(3)  Anidians  (a,  negative  ;  etSos,  form),  in  which  the  organism 
consists  of  a  membranaceous  sac  enclosing  various  soft  formations 
and  bloodvessel  ramifications. 

(B)  Autosites  (aurds,  self ;  crlro?),  in  which  the  essential  organs 
are  sufficiently  developed  to  allow  independent  progressive 
development. 

(C)  Parasites  (Trapda-iros,  a  parasite),  which  are  mere  shape- 
less masses,  lacking  even  an  umbilical  cord,  and  adherent  to  the 
maternal  sexual  organ  from  which  they  receive  their  nourishment. 

Only  one  of  these  three  orders  need  be  considered  here,  i.e., 
autosites. 

Autosites. — This  order  is  divided  into  four  families,  according 
as  the  characteristic  malformation  is  of  the  limbs,  trunk,  cranium, 
or  face.     These  are  as  follows  : — 

(1)  Teratomelians  (repots,  a  monster  ;  /xeAos,  a  limb),  in  which  the 
limbs  are  malformed.    They  are  again  divided  into  two  genera  : — ■ 

(a)  Ectromelians  (eKTpwpa,  an  abortion  ;  /xeAos),  in  which 

the  whole  or  part  of  one  or  more  limbs  is  wanting. 

(b)  Symelians  (crw,  together ;  /AeAos),  in  which  one  or  both 

pairs  of  limbs  are  fused  together. 

*  '  Histoire  generate  et  particuliere  des  anomalies  de  l'organisme,'  1832- 
1836. 


SINGLE  MONSTERS  851 

(2)  Tevatosomians  (repas ;  o-w/xa,  the  body),  in  which  there  is  an 
arrest  of  development  of  the  anterior  abdominal  wall 

(3)  Terato-encephaliaiis  (-repa? ;  eyKe</>aAos,  the  brain),  in  which 
there  is  incomplete  development  or  absence  of  the  walls  of  the 
cranial  cavity  or  the  brain.  They  are  again  divided  into  three 
genera : — 

(a)  Exencephalians  (e£,  out ;  ey/<e<£aAos),  in  which  there  is  an 

incomplete  development  of  the  vault  of  the  cranium. 

(b)  Pseudencephalians  (^evS?/s,  false ;  ey/v-e<£aAos),  in  which, 

in  addition  to  an  imperfect  development  of  the  vault 


Fig.  361. — An  Acephalian  Omphalosite. 
(From  a  specimen  in  the  School  of  Physic,  Trinity  College,  Dublin.) 

of  the  cranium,  there  is  also  an  incomplete  develop- 
ment of  the  brain,  which  is  only  represented    by 
some  vascular  tissue. 
(c)  Anencephalians  (a ;  ey/ce^aAos),  in  which  there  is  com- 
plete absence  of  both  cranial  vault  and  brain. 
(4)  Teratocephalians  (repas ;  Ke<£aA-;;),  in  which  there  is  arrested 
development  or  non-formation  of  the  median  portions  of  the  face, 
the  lateral  portion  coalescing  more  or  less  completely  in  the  middle 
line.     They  are  again  divided  into  two  genera  :— 

(a)  Cyclocephalians  (kuk-Aos,  a  circle  ;  Ke(f)a\-)j),  in  which 
the  median  portions  of  the  upper  part  of  the  face 
are  wanting. 

54—2 


852  THE  PATHOLOGY  OF  LABOUR 

(b)  Otocephalians    (ovs,    an    ear ;    KefaXrj),    in    which    the 
median  portions  of  the  lower  parts  of  the  face  are 
wanting. 
All  the  preceding  genera  are  subdivided  into  species,  into  which 
it  is  quite  unnecessary  to  enter  in  a  work  on  obstetrics. 

Single  monsters  do  not  possess  at  all  the  same  obstetrical 
importance  that  double  monsters  possess,  inasmuch  as  they 
seldom  interfere  to  a  serious  extent  with  the  mechanism  of 
labour.  Parasites,  or  as  they  are  often  termed,  acardiac  monsters, 
are  occasionally  met  with  in  cases  in  which  twins  have  developed 
from  a  single  ovum.  If  the  circulation  of  one  twin  is  considerably 
stronger  than  that  of  the  other,  and  if  there  is  a  free  anastomosis 
between  their  respective  umbilical  vessels  at  the  placenta,  the 
stronger  heart  tends  to  drive  its   blood  not  only  into  its  own 


Fig.  362. — An  Anencephalic  Monster. 

Family  :  Terato-encephalian.     Genus  :  Exencephalian.     (From  a  specimen 
in  the  School  of  Physic,  Trinity  College,  Dublin.) 

portion  of  the  placenta,  but  also  into  the  portion  belonging  to 
the  weaker  heart.  This  hampers  the  weaker  heart,  and  makes  it 
become  progressively  weaker  and  finally  cease.  The  stronger 
heart  then  drives  its  blood  not  alone  through  its  own  circulatory 
system,  but  also  through  that  of  the  dead  twin,  and  so  enables  a 
feeble  form  of  growth  to  continue.  As  the  single  heart  is  unable 
to  effectively  discharge  the  duty  of  two,  it  follows  that  only  the 
parts  of  the  dead  foetus  near  the  umbilicus  receive  sufficient  blood 
to  develop  at  all  fully,  and,  consequently,  a  mass  results  in  which 
the  limbs  and  head  may  be  rudimentary  or  completely  wanting 
(v.  Fig.  361).  In  this  way,  the  various  families  which  we  have 
enumerated  above  are  obtained. 

The  commonest  family  of  single  autosite,  that  is  met  with  in 
practice,  is  perhaps  the  terato-encephalian,  in  which  the  vault 
of  the  cranium,  and  perhaps  a  portion  of  the  brain,  is  incom- 
pletely developed  or  absent.  These  monsters  are  usually  termed 
anencephalic   monsters,  though    correctly  that   term    should   be 


DOUBLE  MONSTERS 


853 


only  applied  to  a  single  genus.  The  diagnosis  of  the  presenta- 
tion by  vaginal  examination  is  often  extremely  puzzling  in  these 
cases.  As  a  rule,  the  neck  of  the  monster  is  very  short,  and 
consequently  neither  flexion  nor  extension  occurs.  The  head  is 
usually  small,  and  so  is  able  to  pass  through  the  pelvis  with  what 
ought  to  be  the  vertex,  or  perhaps  the  brow,  presenting.  This 
region  is,  however,  represented  by  a  gap  in  the  cranial  vault 
filled  in  by  a  membrane,  and  possessing  very  irregular  edges 
(v.  Figs.  362,  363).  If  the  condition  has  been  once  felt  per  vaginam 
it  will  be  recognised  in  subsequent  cases,  but  the  first  time  it 
is  met  with  it  is  puzzling. 


Double  Monsters. 

Double  monsters  are  of  considerably  more  importance  from  an 
obstetrical  point  of  view  than  are  single  monsters,  as  they  cause 


Fig.  362. — Back  View  of  Anencephalic  Monster  shown  in  Fig.  363. 


considerable  difficulty  during  delivery, 
two  main  orders  : — 


They  are  divided  into 


(A)  Double  Autosites,  composed  of  two  almost  equally 
developed  individuals. 

(B)  Double  Parasites,  composed  of  the  union  of  a  single 
autosite  with  a  single  omphalosite  or  parasite. 

(A)  Double  Autosites. — Double  autosites  are  divided  into  three 
families  :  — 

(1)  Teratopagians  (repas  ;  -n-ayrj,  anything  that  holds  fast,  hence 
a  union),  in  which  two  complete  individuals  are  united  to  one 
another  by  a  single  region  of  the  body.  This  family  is  divided 
into  two  genera  : — 

(a)  Eusomphalians    (eS,    well ;    d/^aAos),    in    which    each 

individual  has  an  umbilicus  and  an  umbilical  cord. 

(b)  Monomphalians    (/jlovos,    single ;     d/j<£aAds),    in   which 

there  is  a  common  umbilicus  and  umbilical  cord. 


854  THE  PATHOLOGY  OF  LABOUR 

(2)  Teradelphians  (repa<s ;  aSeA^os,  a  brother,)  in  which  the  two 
individuals  are  separate  below  the  umbilicus,  but  are  united  to  a 
varying  degree  between  the  head  and  the  umbilicus.  This  family- 
is  divided  into  two  genera  : — 

(a)  Sycephalians   {uvv ;   Ke^aX-j),   in   which    there  is  close 

fusion  of  the  heads  and  of  the  bodies,  from  the 
umbilicus  upwards. 

(b)  Monocephalians  (jxovos  ;  Ke^aX-q),  in  which  there  is  a 

single  head  with  no  external  trace  of  duplicity,  and 
two  more  or  less  completely  fused  trunks. 

(3)  Teratodymes  (repas ;  SiSvfios,  double),  in  which  the  cephalic 
extremities  are  independent,  but  the  pelvic  extremities  are  com- 
pletely united,  thus  making  them  the  reverse  of  teradelphians. 
They  are  divided  into  two  genera  : — ■ 

(a)  Sysomians    (a-vv ;    o-w/m),    in    which    there    are    two 

recognisable  but  more  or  less  fused  trunks  with 
distinct  heads  rising  from  a  common  pelvis  and 
lower  limbs. 

(b)  Monosomians  (/xovos  ;  o-w/m),  in  which  there  is  a  single 

body  with  no  external  trace  of  duplicity,  and  two 
more  or  less  completely  fused  heads. 

(B)  Double  Parasites. — Double  parasites  are  divided  into  five 
families,  as  follows  : — 

(1)  Heterotypians  (eVepos,  other;  tvttos,  a  type),  in  which  a 
parasite  is  connected  with  an  autosite  in  a  similar  manner  to  that 
in  which  any  of  the  three  families  of  double  autosites  are  con- 
nected with  one  another. 

(2)  Hetevalians  (eVepos ;  alius,  another),  in  which  the  parasite 
consists  of  a  single  part  of  another  foetus  and  is  engrafted  on  any 
part  of  the  autosite.  Thus,  an  accessory  head  may  be  grafted  on 
to  the  head  of  an  autosite. 

(3)  Polygnathians  (ttoXvs,  many  ;  yvddos,  a  jaw),  in  which  the 
parasite  is  formed  of  the  maxillae  or  other  portion  of  the  head  and 
is  grafted  on  to  the  maxillae  of  the  autosite. 

(4)  Polymelians  (ttoXvs  ;  [xeXos,  a  limb),  in  which  the  parasite 
consists  of  one  or  more  limbs  grafted  on  the  autosite. 

(5)  Endocymians  (eVSor,  within  ;  Ku/m,  a  foetus),  in  which  the 
parasite  is  enclosed  within  the  autosite,  usually  in  the  abdominal 
cavity. 

In  the  foregoing  list  we  have  omitted  all  reference  to  species, 
as  to  include  them  would  mean  unduly  extending  the  classifica- 
tion. It  must  be  remembered  that  triple  monsters  may  occur, 
and  that  they  can  be  classified  in  a  similar  manner  to  double 
monsters. 

Double  monsters  are  of  considerably  more  importance  from 
an  obstetrical  point  of  view  than  are  single  monsters,  as,  unless 
they  are  very  small,  they  will  always  give  rise  to  difficulty  during 
delivery.     In  discussing  them  from  this  point  of  view,  a  more 


DOUBLE  MONSTERS 


«55 


general  classification  than  that  which  we  have  given  above  must 
be  adopted,  and  so,  for  practical  purposes,  we  shall  divide  them 
into  two  main  classes  : — 

(A)  Those  in  which  one  end  of  the  body  is  double.     This  class 
may  be  further  divided  into  two  groups  : — 

(i)  Those  in  which  the  cephalic  end  is  double,  a  type  of 
which  is  seen  in  some  of  the  species  of  the  Symosian 
genus  of  the  family  Teratodyme,  and  notably  in  the 
species  known  as  Psodyme  (^6a,  the  loin  ;  8c8vfios) ; 
(v.  Fig.  364). 


Fig.  364 
Family :  Teratodyme.     Genus 


-A  Teratodyme. 


Symosian.     Species :  Psodyme.     (From 
a  specimen  in  the  School  of  Physic,  Trinity  College,  Dublin.) 

(2)  Those  in  which  the  podalic  end  is  double,  a  type  of 
which  is  seen  in  some  of  the  species  of  the 
Sycephalian  genus  of  the  Teradelphian  family, 
especially  in  that  species  known  as  Iniopes  (IvLov, 
the  occiput ;  o\p,  the  eye) ;  (v.  Fig.  365). 

(B)  Those  in  which  there  are  two  outwardly  distinct  infants, 
which  are  more  or  less  closely  connected.  This  class  may  be 
divided  into  three  groups,  all  of  which  are  met  with  as  species  of 
the  Teratopagian  family.     These  groups  are  as  follows  : — 


856 


THE  PATHOLOGY  OF  LABOUR 

(i)  Those  in  which  the  infants  are  united  at  the  level  or 
the  head — cephalopagous  (xa^aXr)  ;  Trayf])  monsters. 

(2)  Those  in  which  the  infants  are  united  at  the  level  of 

the  thorax — thoracopagous  (6>wpa^,  the  chest ;  7ray?}) 
monsters,  or  at  the  level  of  the  xiphoid  cartilage 
— xiphopagous  (£t</>os,  a  sword  ■  irayrj)  monsters 
{v.  Fig.  366). 

(3)  Those  in  which  the  infants  are  united  at  the  level  of 

the  pelvis — ischiopagous  (tVxtov,  the  hip ;  irayi)) 
monsters  (v.  Fig.  367). 


Fig.  365.— A  Teradelphian, 

Family  :    Teradelphian.     Genus  :    Sycephalian.     Species :    Iniopes.      (From  a 

specimen.) 


Diagnosis. — The  diagnosis  of  the  presence  of  a  double  monster 
is  by  no  means  easy,  and  is  rarely  made  until  either  spontaneous 
expulsion  takes  place,  or  an  obstruction  to  delivery  necessitates 
the  passage  of  the  hand  into  the  uterus.  A  suspicion  of  the  con- 
dition of  affairs  present  may  be  obtained  by  abdominal  palpation, 
but  it  is  obvious  that  it  is  always  extremely  difficult  to  distinguish 
between  a  double  monster  and  an  ordinary  twin  pregnancy,  and 


DOUBLE  MONSTERS  857 

that  sometimes — as  in  cases  where  there  are  two  outwardly  dis- 
tinct infants — it  is  impossible  to  do  so.  In  cases  in  which  only 
one  extremity  is  doubled,  a  diagnosis  may  be  made  by  finding  on 
careful  palpation  three  'large  parts' — i.e.,  heads  or  breeches, 
and  by  hearing  on  auscultation  only  one  foetal  heart. 

Treatment. — If  a  diagnosis  of  double  monster  is  made,  there  is 
a  general  rule  of  treatment,  namely,  to  pass  the  hand  into  the 
uterus,  endeavour  to  ascertain  the  nature  of  the  monstrosity,  and 


Fig.  366. — A  Xiphopagous  Monster 

Family  :  Teratopagian.     Species  :  Eusomphalian.     (From  a  specimen 
in  the  School  of  Physic,  Trinity  College,  Dublin.) 

bring  down  all  the  feet.     Then,  if  the  natural   efforts  are  not 
sufficient  to  bring  about  delivery,  apply  traction. 

Spiegelberg*  advises  that,  during  the  extraction,  both  trunks 
should  be  brought  into  the  oblique  diameter  of  the  pelvis,  with 
the  object  of  preventing  the  hitching  of  the  heads  above  the 
promontory  or  anterior  pelvic  wall.  It  may  then  be  possible  to 
induce  the  posterior  head  to  enter  the  pelvis  first,  and  to  pass  into 
the  sacral  concavity,  if  the  trunks  are  carried  well  forward  over  the 
*  Op.  cit.,  vol.  ii.,  p.  175. 


THE  PATHOLOGY  OF  LABOUR 


abdomen  of  the  mother,  as  this  causes  the  anterior  head  to  move 
upwards  and  backwards  over  the  brim  of  the  pelvis,  and  so  retards 
its  descent.     If  version  cannot  be  performed,  or  if,  after  its  per- 


Fig.  367. — An  Ischiopagous  Monster. 

Family  :  Teratopagian.     Genus  :  Monomphalian.     (From  a  specimen 
in  the  Royal  College  of  Surgeons,  Dublin.) 

formance,  extraction  is  impossible,  embryotomy  must  be  performed 
with  the  object  of  separating  the  two  infants  or  of  removing  the 
doubled  extremity. 


CHAPTER  IX 
POSTPARTUM  HEMORRHAGE 

Primary  Post-partum  Haemorrhage  —  Traumatic  Haemorrhage:  External, 
Internal  —  Atonic  Haemorrhage  —  Concealed  Atonic  Haemorrhage. 
Secondary  Post-partum  Haemorrhage.  Post-haemorrhagic  Collapse — 
Infusion  of  Saline  Solution.     Retention  of  the  Placenta. 

PRIMARY  POST-PARTUM  HEMORRHAGE 

Primary  post-partum  haemorrhage  is  the  term  applied  to  haemor- 
rhage occurring  at  any  time  within  six  hours  after  the  birth  of 
the  child.  It  is  one  of  the  commonest  accidents  met  with  in 
midwifery.     There  are  two  distinct  varieties  : — 

I.  Traumatic  haemorrhage. 
II.  Atonic  haemorrhage. 

Traumatic  Haemorrhage. 

The  term  traumatic  haemorrhage  is  applied  to  haemorrhage  due 
to  laceration  of  any  part  of  the  genital  tract,  the  result  of  direct 
or  indirect  violence  Bleeding  due  to  rupture  of  the  uterus  is 
not,  however,  included  under  this  head,  as,  in  the  majority  of 
cases  of  rupture,  haemorrhage  is  only  one  of  several  symptoms, 
and,  consequently,  is  better  dealt  with  under  the  head  of  rupture 
of  the  uterus. 

Varieties. — Two  varieties  of  traumatic  haemorrhage  are  met 
with  : — External  traumatic  haemorrhage  ;  and  internal  traumatic 
haemorrhage. 

External  Traumatic  Hemorrhage.  —  External  traumatic 
haemorrhage,  in  which  the  blood  escapes  externally,  is  very  much 
the  more  common  variety. 

Aetiology. — External  haemorrhage  may  result  from  lacerations 
occurring  about  the  clitoris,  perinaeum,  or  cervix  during  the 
expulsion  of  the  child.  Perinaeal  lacerations  very  rarely  bleed  to 
an  extent  sufficient  to  justify  the  name  haemorrhage. 

Symptoms. — The  symptom  of  the  case  is  a  varying  amount  of 

859 


86o  THE  PATHOLOGY  OF  LABOUR 

haemorrhage,  which  is  not  affected  by  the  contractions  of  the 
uterus. 

Diagnosis.  —  External  traumatic  haemorrhage  has  to  be  dis- 
tinguished from  atonic  haemorrhage,  that  is,  from  haemorrhage 
due  to  failure  of  the  uterus  to  contract.  In  practice  we  find  that, 
as  a  rule,  we  commence  to  treat  all  cases  as  if  they  were  atonic 
haemorrhage,  and  that  it  is  owing  to  various  points  which  are  noticed 
during  this  treatment  that  we  make  the  diagnosis  of  traumatic 
haemorrhage.  The  first  of  these  points  is  that  the  bleeding  is 
found  to  be  unaffected  by  the  contractions  of  the  uterus  ;  the 
patient  bleeding  as  rapidly  when  the  uterus  is  contracted  as 
when  it  is  lax.  The  second  is  that  while  we  are  douching  out 
the  uterus  or  vagina  with  a  double-channel  catheter  we  notice 
that  though  blood  is  flowing  over  the  vulva,  the  fluid  which  is 
returning  through  the  catheter  is  colourless.  If  the  haemorrhage 
is  coming  from  a  laceration  of  the  clitoris  or  perinaeum,  this  point 
is  noticed  when  the  nozzle  of  the  catheter  is  in  the  vagina ;  if 
from  the  vagina  or  cervix,  when  the  nozzle  is  in  the  uterus.  As 
soon  as  we  have  in  this  manner  roughly  localised  the  site  of  the 
haemorrhage,  the  exact  bleeding  spot  can  be  found  by  careful 
examination. 

Treatment. — If  the  haemorrhage  is  found  to  come  from  a  lacera- 
tion of  the  clitoris,  the  easiest  and  most  effective  method  of 
checking  it  is  to  pass  a  silk  suture  with  a  small  curved  needle 
deeply  beneath  each  end  of  the  laceration.  These  sutures,  which 
may  if  necessary  be  passed  quite  down  to  the  bone,  are  then  tied, 
and,  as  a  rule,  the  haemorrhage  immediately  ceases.  If  the  tear 
is  of  considerable  extent,  a  third  suture  may  be  passed  between 
the  others.  These  sutures  are  removed  on  the  eighth  day. 
Occasionally,  bleeding  follows  their  removal,  but,  if  so,  it  can 
always  be  checked  by  applying  a  firm  compress  for  a  few  hours. 

If  the  haemorrhage  is  coming  from  the  perinaeum,  it  will  be 
checked  by  the  ordinary  sutures,  which  are  inserted  to  bring 
together  the  lacerated  perinaeal  body.  Haemorrhage  coming  from 
a  cervical  laceration  is  the  most  troublesome  to  check,  on  account 
of  the  difficulty  of  exposing  and  suturing  the  laceration.  The 
method  of  doing  so  will  be  subsequently  described. 

Prognosis. — The  prognosis  of  external  traumatic  haemorrhage  is 
always  good,  unless  the  case  is  either  neglected  or  improperly 
treated.  A  cervical  laceration  may,  however,  be  extremely  serious 
in  cases  of  low  insertion  of  the  placenta,  owing  to  its  proximity 
to  the  uterine  sinuses. 

Internal  Traumatic  Hemorrhage.  —  Internal  traumatic 
haemorrhage  is  the  term  applied  to  traumatic  haemorrhage  in 
which  the  blood  instead  of  escaping  externally  flows  into  the 
peri-vaginal  or  peri-vulvar  tissues.  If  this  occurs,  a  haematoma 
forms  of  varying  size,  and  to  this  condition  has  been  given  the 
name  of  hematoma  vagina  et  vulva. 


INTERNAL  TRAUMATIC  HEMORRHAGE 


861 


Frequency. — Internal  traumatic  haemorrhage,  sufficient  in  amount 
to  require  treatment,  is  a  very  rare  occurrence.  Statistics  of  its 
relative  frequency  are  difficult  to  obtain.  Winckel  estimates  its 
frequency  at  i  in  1,000,  Hugenberger  at  n  in  14,000.  At  the 
Rotunda  Hospital,  there  were  10  cases  in  20,000  deliveries. 


Fig.  368. — Hematoma  of  the  Vulva.     (Bumm.) 


.Etiology. — The  direct  cause  of  the  condition  is  the  rupture  of 
a  vein  in  the  tissue  beneath  the  lowest  part  of  the  vaginal  wall, 
or,  more  rarely,  beneath  the  vulvar  mucous  membrane  (Winckel). 
The  cause   of  the   rupture  is  sometimes  to  be  found  in   great 


862  THE  PATHOLOGY  OF  LABOUR 

stretching  of  the  vaginal  walls,  especially  when  very  rapidly 
accomplished,  in  the  existence  of  vulvo-vaginal  varices,  or  as  the 
result  of  subsequent  sloughing  of  the  coats  of  a  bloodvessel,  the 
result  of  long-continued  pressure.  In  the  majority  of  cases  of 
this  kind,  no  assignable  cause  can  be  found,  and  the  rupture  of 
the  vessel  may  have  been  due  to  a  pre-existing  abnormal  thinness 
of  its  coats,  or  to  the  gliding  of  the  vaginal  wall  over  the  deeper 
structures  as  the  vagina  is  drawn  upwards  during  labour,  a  gliding 
which  may  be  associated  with  laceration  of  a  vessel  (Perret).  A 
strong  predisposing  element  to  rupture,  and  one  which  is  present 
in  all  labours,  is  obstruction  to  the  venous  return  during  the 
descent  of  the  head,  as  this  tends  to  produce  thinning  of  the  walls 
of  the  veins  by  overdistension. 

Pathological  Anatomy.- — -These  haemorrhages  may  occur  either 
below  or  above  the  pelvic  diaphragm,  and,  consequently,  can  be 
divided  into  infra-fascial  and  supra-fascial.  Infra-fascial  haema- 
tomata  usually  form  at  one  side  of  the  lower  portion  of  the 
vaginal  canal.  If  they  form  externally,  they  are  most  frequently 
situated  in  the  labia  majora,  more  rarely  in  the  labia  minora,  or 
in  the  remains  of  the  hymen  or  perinaeum.  A  well-defined 
tumour  usually  results,  varying  in  size  from  that  of  a  hen's  egg 
to  that  of  a  foetal  head.  In  some  cases,  the  haemorrhage  may 
extend  in  all  directions,  surround  the  whole  vulva  and  vagina, 
and  extend  downwards  upon  the  thighs.  Sometimes,  as  the 
result  of  perforation  of  the  pelvic  fascia  from  sloughing,  such 
haemorrhage  may  extend  upwards,  as  in  supra-fascial  haema- 
tomata.  Primary  supra-fascial  haematomata  are  very  rare.  If  a 
vessel  ruptures  in  this  region,  blood  may  collect  round  the  upper 
part  of  the  vagina,  and  then  extend  upwards  in  all  directions 
beneath  the  peritoneum,  reaching  the  kidneys  behind,  the  level 
of  the  umbilicus  in  front,  and  the  iliac  crests  laterally. 

Symptoms. — A  haematoma  may  commence  to  form  during 
delivery,  but,  although  the  vessel  may  be  torn  prior  to  the  expul- 
sion of  the  child,  the  pressure  of  the  head  will  usually  prevent 
the  escape  of  blood  until  after  that  event.  Whether  the  child 
has  been  expelled  or  not,  the  first  symptom  of  the  condition  is 
intense  pain,  associated  with  swelling  in  the  neighbourhood  of 
the  ruptured  vessel.  In  a  short  time,  a  small  tumour  forms/ 
elastic  to  the  touch  and  of  a  blue  colour,  and  gradually  increases 
in  size.  If  the  haemorrhage  continues  and  the  case  is  not  treated, 
this  tumour  may  rupture  and  the  bleeding  become  external.  At 
the  same  time,  the  patient  becomes  collapsed  and  anaemic  in  pro- 
portion to  the  amount  of  blood  lost. 

Terminations. — Internal  traumatic  haemorrhage,  if  allowed  to 
remain  untreated,  may  terminate  in  one  of  the  following  ways  : — 

(i)  The  tumour  may  rupture,  and  free  external  haemorrhage 
result,  which  may  or  may  not  prove  fatal. 

(2)  The  haemorrhage  may  extend  interstitially  —  upwards 
towards   the   abdomen,  or  downwards  towards  the  perinaeum — 


ATONIC  HEMORRHAGE  863 

according  as  the  ruptured  vessel  is  above  or  below  the  pelvic 
fascia.  The  patient  may  thus  bleed  to  death  into  her  subcutaneous 
tissue. 

(3)  The  tumour  if  small  may  be  absorbed  aseptically. 

(4)  Suppuration  or  decomposition  of  the  contents  of  the  tumour 
may  occur. 

Treatment. — If  the  condition  is  recognised  before  the  birth  of  the 
child  the  latter  should  be  delivered  immediately.  If  the  amount 
of  effused  blood  is  small,  the  forceps  can  be  applied  in  the 
ordinary  manner.  If,  however,  the  size  of  the  tumour  is  so  great 
as  to  obstruct  delivery,  its  walls  must  be  incised,  its  contents 
turned  out,  a  piece  of  iodoform  gauze  placed  over  the  opening, 
and  the  child  delivered  as  quickly  as  possible.  If  the  tumour  has 
not  been  incised,  and  if  it  increases  slowly  in  size  after  delivery,  the 
effects  of  firm  pressure  upon  it  may  be  tried.  If  this  fails,  or  if 
the  increase  in  size  has  been  very  rapid,  it  will  be  necessary  to 
incise  its  walls  and  turn  out  the  contents.  In  every  casein  which 
incision  is  practised,  and  the  cavity  is  of  large  size,  the  latter 
should  be  douched  out  and  then  firmly  plugged  with  iodoform 
gauze.  This  plugging  must  be  changed  every  day  until  the 
cavity  is  obliterated.  If  the  cavity  is  small,  deep  sutures  passed 
beneath  it,  so  as  to  bring  its  walls  together  when  they  are  tied, 
will  be  found  to  be  more  satisfactory  than  the  plug. 

If  the  tumour  is  of  small  size  it  may  be  left  to  absorb.  If 
suppuration  occurs,  the  abscess  must  be  opened  at  the  spot  at 
which  it  points,  the  pus  evacuated,  and  the  cavity  plugged  with 
iodoform  gauze. 

Prognosis. — The  prognosis  depends  upon  the  treatment  adopted 
and  on  the  situation  of  the  haemorrhage.  Supra-fascial  bleeding 
is  very  much  more  dangerous  than  is  infra-fascial,  on  account  of 
the  difficulty  of  checking  it.  In  either  case,  the  patient  may  die 
from  the  continuance  of  haemorrhage  or  from  sepsis.  In  the  usual 
form  of  haematoma  neither  will  occur,  if  the  case  is  properly  treated. 

Atonic  Hemorrhage. 

Atonic  post-partum  haemorrhage  is  the  term  applied  to  haemor- 
rhage due  to  the  failure  of  the  uterus  to  contract.  Loss  of  blood 
occurs  to  a  very  slight  extent  in  almost  all  cases  of  labour,  as  it 
is  impossible  for  the  placenta  to  be  detached  and  expelled  without 
such  an  occurrence.  It  is  only  when  the  amount  lost  becomes 
excessive  that  the  term  post-partum  haemorrhage  can  be  applied 
to  it.  The  average  amount  of  blood  lost,  taking  clots  and  fluid 
blood  together,  is  four  ounces  before  the  placenta  is  delivered, 
and  six  ounces  with  the  placenta  and  membranes  (Dakin). 
According  to  Winckel,  as  soon  as  the  patient  has  lost  from 
400  to  500  grammes  (fourteen  to  seventeen  ounces)  of  blood,, 
active  treatment  must  be  commenced  with  the  object  of  preventing 
further  loss. 


864  THE  PATHOLOGY  OF  LABOUR 

Frequency. — The  frequency  of  atonic  post-partum  haemorrhage 
is  difficult  to  determine,  as  the  term  post-partum  haemorrhage 
has  been  used  loosely  in  the  past,  and  different  observers  hold 
different  opinions  as  to  the  amount  of  haemorrhage  to  which  the 
term  can  be  applied.  In  the  Rotunda  Hospital,  amongst  20,000 
patients,  there  were  319  cases  of  haemorrhage  which  required 
some  form  of  treatment  more  radical  than  the  massage  of  the 
fundus  and  the  administration  of  ergot,  that  is,  one  case  in 
62-69.  Amongst  these,  a  few  cases  of  traumatic  haemorrhage  are 
included. 

/Etiology. — Before  starting  to  discuss  the  causes  of  atonic  post- 
partum haemorrhage  it  is  well  to  understand  the  factors  which 
normally  prevent  its  occurrence.  The  haemorrhage,  which  occurs 
during  the  detachment  and  expulsion  of  the  placenta,  is  normally 
checked  by  the  united  action  of  three  factors  : — 

(1)  The  Contractions  of  the  Muscular  Coat  of  the  Uterus. — 
The  contractions  of  the  muscular  coat  of  the  uterus  bring  about  a 
temporary  cessation  of  haemorrhage  during  their  occurrence.  Each 
fibre  of  the  uterus  diminishes  in  length,  and  as  a  result  the  whole 
organ  becomes  almost  as  firm  and  hard  as  a  billiard  ball,  and  its 
supplying  arteries  are  compressed.  As  soon  as  the  contraction 
passes  off,  and  it  only  lasts  a  very  short  time,  the  uterine  fibres 
lengthen,  the  compression  of  the  vessels  ceases,  and  haemorrhage 
would  recommence  if  another  factor  quite  distinct  from,  but  in  a 
manner  dependent  on  the  contraction,  did  not  also  occur.  This 
factor,  which  is  the  most  potent  agent  in  causing  the  permanent 
cessation  of  the  haemorrhage,  is  the  retraction  of  the  uterine 
muscle  fibres. 

(2)  The  Retraction  of  the  Uterine  Muscle  Fibres. — Retraction, 
i.e.,  the  permanent  and  progressive  shortening  that  occurs  in  the 
uterine  muscle  fibres  in  consequence  of  contraction,  brings  about 
a  reduction  in  the  size  of  the  uterus,  sufficient  to  cause  a  per- 
manent kinking  and  compression  of  the  placental  vessels.  It  is, 
therefore,  the  process  to  which  the  final  and  permanent  checking 
of  haemorrhage  is  due. 

(3)  The  Clotting  which  occurs  in  the  Mouths  of  the  Vessels.— 
The  clotting  which  occurs  in  the  mouths  of  the  vessels  is  so 
unimportant  a  factor  in  the  checking  of  haemorrhage  that  it  may 
be  almost  neglected.  It  may  be  the  direct  cause  of  the  cessation 
of  haemorrhage  in  some  small  vessels,  but  it  is  probably  more 
correct  to  consider  it  as  the  result  rather  than  as  a  cause  of  the 
cessation  of  haemorrhage. 

The  foregoing  are  the  normal  agencies  by  which  post-partum 
haemorrhage  is  prevented,  and,  knowing  them,  we  are  now  in  a 
better  position  to  understand  what  are  the  conditions  which  will 
favour  the  occurrence  of  haemorrhage.  Speaking  generally,  these 
conditions  may  be  said  to  include  anything  which  tends  to  prevent 
the  due  retraction  of  the  uterine  muscle  fibres,  either  directly,  as  a 
retained  adherent  placenta,  or  indirectly,  by  preventing  contraction 


TREATMENT  OF  ATONIC  HEMORRHAGE  865 

from  taking  place,  as  degeneration  of  the  fibres  from  some  patho- 
logical condition. 

The  following  are  the  principal  causes  of  post-partum  haemor- 
rhage : — 

(1)  Retained  Placental  Fragments,  Membranes,  or  Blood-Clots. 
— Such  a  condition  is  generally  due  to  bad  management  of  the 
third  stage.  Fragments  of  placenta  and  membranes  may,  however, 
also  be  retained  owing  to  their  too  firm  adhesion  to  the  uterine 
wall,  the  result  of  a  former  endometritis. 

(2)  Uterine  Inertia. — This  may  in  turn  be  due  to : — Previous 
overdistension  of  the  uterus,  as  in  hydramnios  and  twins  ;  metritis  ; 
prolonged  labour ;  weak  muscular  development  of  the  uterus  ; 
faulty  shape,  or  maldevelopment  of  the  uterus  ;  tumours. 

(3)  Precipitate  Labour.  —  During  a  precipitate  labour,  the 
uterus  has  not  had  time  to  undergo  the  normal  amount  of  retrac- 
tion, and  consequently  is  not  ready — so  to  speak — for  the  third 
stage. 

(4)  Placenta  Praevia. — In  this  condition,  the  haemorrhage  results 
from  the  non-obliteration  of  the  supplying  vessels  of  that  portion 
of  the  placenta  which  is  attached  to  the  non-contractile  lower 
uterine  segment. 

(5)  Tumours  of  the  Uterus. — These  cause  uterine  inertia,  and 
prevent  the  uniform  retraction  of  the  fibres. 

(6)  Any  Condition  which  weakens  the  Patient.  —  Such  as 
previous  haemorrhages,  and  any  form  of  wasting  disease. 

Diagnosis. — The  diagnosis  of  atonic  haemorrhage  is  made  on 
finding  haemorrhage  coming  from  the  interior  of  a  non-contracted 
or  badly  contracted  uterus. 

Treatment. — The  treatment  of  post-partum  haemorrhage  is  both 
prophylactic  and  curative.  Prophylactic  treatment  consists  in  the 
proper  management  of  the  third  stage.  If  this  third  stage  is 
correctly  managed,  the  frequency  of  post-partum  haemorrhage  is 
reduced  to  a  minimum.  It  has  been  said  that  the  number  of 
cases  of  this  form  of  haemorrhage  which  occur  in  a  doctor's 
practice  are  in  proportion  to  the  want  of  skill  with  which  he 
manages  this  critical  period. 

The  curative  treatment  of  post-partum  haemorrhage  is  most 
satisfactory,  if  it  is  intelligently  carried  out.  It  is  essential  to  have 
a  definite  plan  of  action  laid  down  which  we  know  so  thoroughly 
that  we  shall  follow  it  mechanically,  and  which  is  so  graduated 
as  to  commence  with  the  mildest  measures,  and  then  pass  on — 
if  they  fail — to  others  which  will  be  more  radical.  The  following 
is  such  a  plan  in  the  order  that  should  be  adopted,  and  pre- 
supposing that  the  failure  of  each  measure  in  turn  requires  the 
adoption  of  the  subsequent  one  :  — 

(1)  If  haemorrhage  starts  after  the  birth  of  the  child,  and  if  it  is 
not  checked  by  massage  of  the  fundus,  ascertain  whether  the 
placenta  is  in  the  uterus  or  vagina.  If  the  placenta  is  in  the 
uterus,  try  the  effects  of  massage  for  a  little  longer.     If  this  does 

55 


866  THE  PATHOLOGY  OF  LABOUR 

not   check  the  bleeding,  or  if  the  placenta  was  already  in  the 
vagina — 

(2)  Express  it  by  the  Dublin  method,  if  possible,  and  then 
stimulate  the  fundus  to  contract  by  friction  and  the  administration 
of  ergot.  Up  to  two  drachms  of  the  liquid  extract  of  ergot  may 
be  given  by  the  mouth,  but  more  certain  and  rapid  in  its  action 
is  the  hypodermic  administration  of  citrate  of  ergotinin.  From 
To  t°  ws  °f  a  gram  of  the  latter  maybe  injected.  If  this  still  fails 
to  check  the  bleeding,  or  if  the  placenta  cannot  be  expressed — 

(3)  Place  the  patient  in  the  cross-bed  position,  wash  her  ex- 
ternally, and  douche  the  vagina  with  a  solution  of  creolin  (jss.  to 
a  gallon),  at  a  temperature  of  no°  to  1150  F.,  having  first  passed 
a  catheter,  if  this  has  not  been  done  already.  If  the  placenta  is 
still  in  the  uterus,  remove  it  manually,  as  will  be  subsequently 
described.  Then  douche  out  the  uterus  thoroughly,  and 
administer  ergot,  if  it  has  not  been  already  administered.  If  the 
placenta  has  been  previously  removed  by  expression,  and  if  the 
vaginal  douche  fails  to  check  the  haemorrhage,  a  hot  uterine 
douche  is  given,  creolin  solution  being  used  as  before.  If  the 
bleeding  still  continues — 

(4)  Compress  the  fundus  firmly  between  the  fingers  of  one 
hand  in  the  anterior  fornix  and  the  other  hand  upon  the  abdominal 
wall,  thus  squeezing  out  any  clots  that  may  be  retained,  and  then 
repeat  the  intra-uterine  douche. 

(5)  Introduce  the  hand  into  the  uterus,  and  remove  any  frag- 
ments of  placenta  or  of  membranes  and  all  clots.  Then  repeat 
the  intra-uterine  douche. 

(6)  In  those  cases  in  which  haemorrhage  resists  the  above 
treatment  there  are  still  two  measures  from  which  a  final  choice 
can  be  made.  These  are,  either  to  plug  the  utero-vaginal  canal 
with  iodoform  gauze,  or  to  inject  perchloride  of  iron  into  the 
uterine  cavity.     Of  the  two,  the  former  is  preferable. 

The  use  of  perchloride  of  iron  was  introduced  by  Barnes.*  He 
recommended  that  a  few  ounces  of  Liq.  Ferri  Perchlor.  (B.P.)  be 
injected  into  the  uterine  cavity  from  which  all  clots  have  been 
removed.  Another  and  perhaps  easier  method  of  applying  the 
iron  is  to  add  Liq.  Ferri  Perchlor.  Fort.  (B.P.)  to  warm  water, 
until  a  light  sherry-coloured  fluid  is  produced.  The  uterus  is 
douched  out  with  this  and  then  with  ordinary  creolin  solution. 
Barnes  claimed  that  iron  acts  in  the  following  manner  :■ — ■ 

(a)  It  coagulates  the  blood  in  the  mouth  of  the  vessels. 

(b)  It  constringes  the  tissues  round  the  mouth  of  the  vessels, 
and  so  compresses  the  latter. 

(c)  It  provokes  some  contraction  of  the  muscular  wall  of  the 
uterus. 

The  great  advantage  of  iodoform  gauze  over  iron  is   that  it 
has  no  tendency  to  interfere  with  the  nutrition  of  the  superficial 
portions  of  the  uterine  wall.     Iron,  on  the  other  hand,  causes  a 
*  Trans.  London  Obstet.  Society,  vol.  vii.,  1866 


TREATMENT  OF  ATONIC  HEMORRHAGE 


867 


considerable  superficial  necrosis,  and,  if  saprophytic  germs  gain 
entrance  to  this  dead  tissue,  they  have  a  suitable  pabulum  on 
which  to  live.  Again,  iodoform  gauze  is  as  certain  as  anything 
can  be  in  its  action,  and,  even  if  the  haemorrhage  is  coming  from 
a  large  vessel  which  has  been  torn  across  owing  to  a  laceration 
of  the  uterus,  it  will  in  all  probability  prevent  further  bleeding. 
Iron  may  and  sometimes  does  fail,  and,  if  it  fails,  it  is  impossible 
to  resort  to  plugging,  as,  owing  to  the  manner  in  which  the 
tissues  have  become  constringed,  gauze  could  not  be  introduced. 


Fig.  369. — Bi-maxual  Compression  of  the  Uterus  in  Post-partum 
hemorrhage. 


If  iron  is  used,  the  uterus  must  be  douched  out  next  day,  and 
each  subsequent  day  if  there  is  any  rise  of  temperature. 

The  foregoing  is  the  mode  of  treatment  which  we  consider 
to  be  most  suitable  in  cases  of  atonic  post-partum  haemorrhage. 
It  is,  of  course,  impossible  to  follow  a  stereotyped  plan  in  all 
cases.  Special  cases  call  for  special  variations  in  the  treatment, 
and  in  some  instances  it  may  be  necessary  to  resort  immediately 
to  the  plug  owing  to  the  condition  of  the  patient.  However, 
in  the  majority  of  cases  in  which  the  accoucheur  has  been  in 
attendance  from  the  onset  of  the  haemorrhage,  it  will  be  possible 
to  follow  a  system  such  as  the  above,  and  so  to  save  the  patient 

55—2 


868  THE  PATHOLOGY  OF  "LABOUR 

from  the  risk  of  intra-uterine  manipulations  in  all  but  the  most 
serious  cases. 

There  are  two  procedures  which  are  very  frequently  recom- 
mended, and  which  have  not  been  mentioned.  They  are  of  use 
in  some  cases,  and,  even  if  they  will,  not  finally  check  the 
haemorrhage,  they  may  cheek  it  temporarily.  The  first  of  these 
is  compression  of  the  aorta.  Unless  the  patient  is  very  stout  or 
strains  very  hard,  it  is  comparatively  easy  to  compress  the  aorta 
through  the  abdominal  wall  against  the  lumbar  portion  of  the 
spinal  column.  It  is  a  procedure  which  is  of  value,  if  we  have 
an  assistant  capable  of  performing  it,  while  preparations  are  being 
made  for  intra-uterine  treatment.  The  second  procedure  is  the 
bi-manual  compression  of  the  uterus,  not  as  recommended  above 
with  the  object  of  expressing  clots,  but  rather  with  the  object 
of  preventing  further  haemorrhage  by  compressing  the  bleeding 
vessels.  It  is  carried  out  as  follows  : — Pass  the  right  hand  into 
the  vagina  and  place  two  fingers  behind  the  cervix  in  the  posterior 
fornix.  With  these  fingers  press  the  cervix  forwards  in  such  a 
manner  as  to  fold  it  beneath  the  body  of  the  uterus  (v.  Fig.  369). 
Then,  compress  the  latter  as  firmly  as  possible  between  the  vaginal 
hand  and  the  left  hand  placed  upon  the  abdominal  wall.  This 
procedure  is  also  of  use  only  in  order  to  gain  time,  as  it  will  rarely 
finally  arrest  the  haemorrhage. 

There  are  a  few  methods  of  treatment  against  which  the  author 
would  like  to  warn  the  student.  These  are  the  intra-uterine 
injection  of  vinegar,  the  freedom  of  which  from  bacteria  can 
never  be  assumed  ;  the  application  of  ice  or  the  pouring  of  cold 
water  on  the  patient's  abdomen,  a  practice  which  is  sufficient  to 
determine  the  death  from  heart  failure  of  a  collapsed  patient ;  the 
introduction  of  ice  into  the  uterus,  both  on  account  of  the  risk 
of  sepsis  and  of  the  shock  it  causes  ;  the  injection  of  ergot  before 
the  placenta  has  left  the  uterus,  unless  we  are  prepared  to  remove 
it  immediately  ;  and  the'  plugging  of  the  uterine  cavity  with  any 
material  which  is  not  sterile. 

Prognosis.  — The  prognosis  of  post-partum  haemorrhage  is 
always  good,  if  the  case  is  taken  in  time.  A  woman  can  lose 
immediately  after  delivery,  without  being  very  much  affected,  an 
amount  of  blood  which  at  another  time  would  bring  her  to  the 
point  of  death. 

Concealed  Atonic  Hemorrhage.  —  The  term  concealed 
atonic  haemorrhage  is  applied  to  post-partum  haemorrhage  when 
the  escaped  blood  is  stored  up  in  the  uterus  instead  of  pouring 
out  through  the  vulva.  It  is  to  a  large  extent  an  artificial  con- 
dition, that  is  to  say,  it  is  caused  by  the  attendant  compressing 
the  lower  uterine  segment  instead  of  the  fundus,  and  so  placing  an 
obstruction  in  the  way  of  the  escape  of  the  blood.  If  the  fundus 
is  not  properly  controlled,  concealed  haemorrhage  may  also  occur 
behind  a  detached  placenta  which  is  blocking  the  lower  uterine 


SECONDARY  POST-PARTUM  HEMORRHAGE  869 

segment.  If  it  occurs,  it  is  recognised  by  the  increase  in  size  of  the 
uterus.  Its  treatment  consists  in  immediately  removing  the  ob- 
struction to  the  escape  of  blood,  and  then  emptying  the  uterus  by 
expression.  If  the  haemorrhage  still  continues,  the  further  treat- 
ment of  the  case  is  similar  to  that  of  external  atonic  haemorrhage. 


SECONDARY  POST-PARTUM  HEMORRHAGE 

The  term  secondary  post  partum  haemorrhage  is  applied  to 
bleeding  coming  on  more  than  six  hours  after  the  completion  of 
labour.     It  is  also  known  as  puerperal  or  late  haemorrhage. 

Frequency. — At  the  Rotunda  Hospital,  in  which  patients  remain 
for  eight  days  after  their  confinement,  26  cases  of  secondary 
haemorrhage  occurred  in  20,000  confinements,  a  proportion  of 
1  in  769-23. 

Aetiology. — Secondary  post-partum  haemorrhage  may  arise  in 
three  ways  : — - 

(1)  Owing  to  the  separation  of  the  thrombi  in  the  mouths  of 
the  uterine  bloodvessels.  This  may  occur  as  a  result  of  a  sudden 
increase  in  the  blood-pressure,  or  of  the  sloughing  of  the  coats 
of  a  vessel  as  a  result  of  a  long-continued  pressure  during  labour. 

(2)  Owing  to  a  congested  condition  of  the  endometrium.  The 
commonest  cause  of  congestion  of  the  endometrium  during  the 
puerperium  is  a  relaxed  condition  of  the  uterus.  This  condition, 
which  is  known  as  sub-involution,  may  be  caused  by  the  retention 
of  pieces  of  placenta  or  membrane,  malpositions  of  the  uterus, 
focal  accumulations,  or  by  the  patient  getting  up  too  soon  after 
labour. 

(3)  Owing  to  the  presence  of  tumours,  either  pre-existing  or 
arising  subsequent  to  delivery.  Amongst  pre-existing  tumours, 
myomata  of  the  body  of  the  uterus  are  the  commonest.  The 
only  tumour  which  is  likely  to  form  subsequent  to  delivery  is 
chorion-epithelioma. 

Treatment. —  If  the  haemorrhage  is  slight,  the  administration  of 
ergot  in  full  doses,  the  expression  of  all  clots  from  the  uterus, 
and  absolute  rest  in  bed,  may  be  sufficient  to  check  it.  If  it 
does  not  cease,  or  if  it  is  severe  from  the  start,  the  vagina  and 
uterus  should  be  douched  out  with  hot  creolin  lotion,  and  the 
latter  explored  with  the  fingers  in  order  to  ascertain  the  cause  of 
the  haemorrhage.  If  a  retrodeviation  of  the  uterus  is  present  it 
must  be  corrected,  and  a  pessary  inserted  if  the  uterus  does  not 
remain  in  the  normal  position.  If  a  portion  of  placenta  has 
been  left  behind,  it  must  be  removed  with  the  finger  or  blunt 
curette.  If  haemorrhage  still  continues,  the  uterine  cavity  must 
be  plugged  with  iodoform  gauze.  In  addition,  the  bowels  must 
be  regulated,  and  the  administration  of  ergot  continued  for 
some  days.  If  the  haemorrhage  is  due  to  the  presence  of  a 
myoma,  and  the  bleeding  cannot  be  checked  by  the  use  of  ergot, 


870  THE  PATHOLOGY  OF  LABOUR 

hot  douches,  and  plugging,  it  may  be  necessary  to  discuss  the 
advisability  of  hysterectomy  or  myomectomy,  according  to  the 
situation  of  the  tumour.  If  the  latter  is  pedunculated,  it  can, 
of  course,  be  easily  removed.  Indeed,  this  should  be  done  in  all 
cases  as  soon  as  the  condition  is  recognised,  as  the  risk  of  the 
sloughing  of  such  a  tumour  after  delivery  is  very  considerable. 
Chorion-epithelioma  admits  of  but  one  treatment — immediate  and 
complete  hysterectomy. 


POST-H^EMORRHAGIC    COLLAPSE 

The  very  favourable  results  which  attend  the  early  recognition 
and  treatment  of  post-haemorrhagic  collapse  are  so  marked  that 
it  is  deemed  advisable  to  devote  a  separate  section  to  this  con- 
dition. 

Symptoms. — The  symptoms  of  collapse  due  to  excessive  loss 
of  blood  are  characteristic.  At  first,  there  is  no  noticeable 
change  in  the  condition  of  the  patient,  save  a  slight  increase  in 
the  frequency  of  the  heart.  As  the  haemorrhage  continues  this 
becomes  more  marked,  and  the  pulse  at  the  same  time  becomes 
small  and  feeble.  Gradually,  the  aspect  of  the  patient  becomes 
blanched,  the  sclerotics  especially  being  of  a  pearly  white  colour, 
respiration  is  more  hurried,  and  the  patient  frequently  sighs. 
This  condition,  which  is  known  as  air-hunger,  is  the  result  of  the 
lessened  amount  of  oxygen  which  the  diminished  blood-stream 
carries  to  the  tissues  and  the  medulla  oblongata.  If  the  tem- 
perature is  taken,  it  is  found  to  have  fallen  from  one  to  three 
degrees.  As  the  haemorrhage  continues,  the  above  symptoms 
become  more  marked.  The  pulse  becomes  uncountable  and 
finally  imperceptible,  and  the  body  is  covered  by  a  cold  sweat. 
Hurried  respiration  is  replaced  by  dyspnoea,  and  the  patient, 
struggling  for  breath,  requests  to  be  raised  as  high  as  possible. 
If  this  is  done,  she  probably  loses  consciousness  momentarily,  or 
the  sudden  elevation  of  the  head  may  be  even  sufficient  to  cause 
the  final  failure  of  the  heart.  She  gradually  becomes  more  and 
more  restless,  complains  of  inability  to  see,  and  finally  becomes 
comatose,  with  perhaps  occasional  convulsive  movements. 

Treatment. — When  a  patient  loses  a  large  quantity  of  blood, 
death  threatens,  not  because  there  is  an  insufficient  quantity  of 
blood  in  the  body,  but  because  the  bloodvessels  have  not  as 
yet  had  time  to  suit  their  capacity  to  the  diminished  amount 
of  fluid  which  they  now  contain.  As  a  matter  of  fact,  a  woman 
greatly  collapsed  from  post-partum  haemorrhage  is  said  to  have 
as  many  red  blood  corpuscles  in  her  body  as  an  anaemic  girl.  In 
consequence  of  the  unfilled  condition  of  the  vessels,  blood  does 
not  return  to  the  heart  in  sufficient  quantities,  the  latter  has 
nothing  to  contract  upon,  and,  as  a  result,  its  contractions  become 
more  and  more  feeble,  and  an  insufficient  qilantity  of  blood  is 


POST-LUEMORRHAGIC    COLLAPSE  871 

sent  to  the  brain.  In  consequence  of  the  resulting  anaemia  of  the 
brain,  feeble  stimuli  are  transmitted  to  the  heart,  which  fails  still 
more,  a  vicious  circle  being  thus  established.  Reasoning  from 
this,  we  see  that,  to  successfully  combat  the  tendency  to  cardiac 
failure,  our  treatment  must  be  directed  towards  three  points : — 

(1)  The  heart  must  be  directly  stimulated.  Direct  stimulation 
of  the  heart  can  be  performed  by  the  administration  of  alcohol  by 
the  mouth  ;  by  the  hypodermic  injection  of  ether,  strychnine,  or 
brandy  ;  by  the  rectal  injection  of  brandy  or  coffee ;  and  by  the 
use  of  hot  fomenlfetions  over  the  precordial  area.  In  administer- 
ing alcohol  by  the  mouth,  we  must  be  careful  not  to  give  it  in 
such  large  quantities  as  to  cause  vomiting.  Half  an  ounce  may 
be  given  at  first  of  a  mixture  of  one  part  of  whisky  or  brandy  in 
two  parts  of  water,  followed  by  a  teaspoonful  of  the  same  every 
five  or  ten  minutes.  From  twenty  minims  to  a  drachm  of  ether 
may  be  injected  hypodermically,  and  from  one-twenty-fifth  to 
one-tenth  of  a  grain  of  sulphate  of  strychnine.  Two  or  three 
syringefuls  of  brandy  may  be  used  instead  of  ether,  the  latter 
is,  however,  preferable.  From  half  an  ounce  to  an  ounce  of 
brandy  or  whisky,  mixed  with  from  four  to  eight  ounces  of 
strong,  hot  coffee,  may  be  injected  into  the  rectum. 

(2)  The  diminished  quantity  of  blood  must  be  limited  as  far  as 
possible  to  the  vital  organs  of  the  body,  i.e.,  the  brain  and  viscera. 
This  is  a  most  important  point,  and  one  which  is  frequently  for- 
gotten during  the  carrying  out  of  the  necessary  measures  for 
checking  the  haemorrhage.  An  even  momentary  diminution  in 
the  amount  of  blood  which  is  going  to  the  brain,  due  to  some 
sudden  elevation  of  the  patient's  head,  may  prove  fatal.  While 
the  patient  is  in  the  cross-bed  position  all  pillows  must  be  removed 
from  beneath  her  head,  and,  if  her  condition  is  serious,  the  limbs 
must  be  tightly  bandaged  from  below  upwards,  in  order  to  drive 
the  blood  from  them  to  the  more  important  parts  of  the  body. 
So  soon  as  the  bleeding  has  been  checked,  and  the  patient  has 
been  returned  to  bed,  the  bottom  of  the  latter  must  be  raised  from 
six  inches  to  a  foot  by  placing  bricks  or  other  sufficiently  firm 
support  beneath  the  legs.  Subsequently,  as  the  patient  improves, 
the  bandages  may  be  removed,  and  the  foot  of  the  bed  brought 
gradually  back  to  its  former  level. 

(3)  The  amount  of  fluid  in  the  bloodvessels  must  be  increased. 
The  amount  of  fluid  in  the  bloodvessels  can  be  increased  in  the 
following  ways  :— By  administering  abundance  of  fluid  by  the 
mouth ;  by  rectal  injections  of  salt  and  water ;  and  by  infusing 
saline  solution  directly  into  a  vein,  or  into  the  subcutaneous  con- 
nective tissue.  As  thirst  is  always  present  to  a  marked  degree  in 
these  cases,  it  is  never  difficult  to  get  the  patient  to  drink  large 
quantities  of  fluid  as  soon  as  she  has  rallied  somewhat  from  her 
collapse.  It  is  not,  however,  a  method  of  increasing  the  fluid  in 
the  body  which  can  be  adopted  at  first,  as  sufficient  quantities  to 
have  any  effect  in  this  direction  would  almost   certainly  cause 


872  THE  PATHOLOGY  OF  LABOUR 

vomiting.  Rectal  injections  of  saline  solution  of  the  same  strength 
as  that  infused  into  a  vein  (o-6  per  cent.,  roughly  a  teaspoonful  of 
salt  to  a  pint  of  water)  will  be  absorbed  most  quickly.  From  one 
to  two  pints  may  be  given,  and  repeated  at  intervals  of  two  or 
three  hours.  It  must  be  injected  very  slowly,  as  otherwise  the 
patient  will  not  retain  it. 

Direct  intravenous  infusion  of  saline  solution  is  the  most  rapid 
method  of  increasing  the  amount  of  fluid  in  the  bloodvessels.  It 
is  a  course  of  procedure  which,  while  it  has  many  supporters,  has 
also  a  number  of  opponents  on  the  grounds  af  its  danger  and 
uselessness.  If  it  is  carefully  carried  out,  the  risk  attending  it 
is  by  no  means  great,  while  doubts  with  regard  to  its  value  are 
most  probably  due  to  the  fact  that  it  is  suffering  at  present  from 
the  results  of  previous  overestimation.  Intravenous  infusion 
will  not  bring  back  to  life  a  patient  who  is  in  the  last  stage  of 
collapse  from  haemorrhage,  but,  if  it  is  performed  before  this 
stage  is  reached,  it  will  in  all  probability  prevent  her  from  falling 
into  such  a  state.  To  render  the  proceeding  of  use,  a  sufficient 
quantity  of  fluid  at  a  proper  temperature  must  be  infused. 
The  necessary  amount  will  vary  between  three  and  six  or  even 


E3 


Full  Size 

Fig.  370. — Hossack's  Canula  for  Intravenous  Infusion. 

eight  pints.  No  definite  quantity  can  be  fixed  which  will  suit  all 
cases,  but  the  infusion  must  be  continued  until  there  is  a  marked 
increase  in  the  volume  and  strength  of  the  pulse.  The  solution 
is  used  at  a  temperature  of  ioo°  to  1020  F. 

In  order  that  the  proceeding  may  be  as  free  from  danger  as 
possible,  everything  used  in  the  operation  must  be  sterile,  and  due 
precautions  must  be  taken  to  prevent  the  entrance  of  air  along 
with  the  fluid.  The  apparatus  used  consists  of  the  following 
implements : — A  glass  or  metal  funnel  capable  of  holding  at  least 
two  ounces ;  a  rubber  tube  of  about  three  feet  in  length  ;  a  small 
silver  or  white  metal  canula  with  a  blunt  point ;  and  a  scalpel, 
dissecting  forceps,  small  needles,  needle-holder,  and  fine  silk. 
The  operation  is  performed  as  follows  : — Tie  a  bandage  round 
the  upper  arm  sufficiently  tightly  to  compress  the  veins  but  not 
the  arteries.  By  this  means  the  veins  below  the  bandage  stand 
out  sufficiently  to  be  seen,  and  a  suitable  one  can  be  selected. 
Expose  the  latter  by  means  of  an  incision  about  an  inch  in  length 
made  directly  over  it,  isolate  a  small  portion  of  it,  and  slip  two 
silk  ligatures  beneath  it.  Then,  tie  the  distal  ligature  to  prevent 
haemorrhage.  A  longitudinal  incision  of  sufficient  length  to  admit 
the  tip  of  the  canula  is  made  in  the  vein,  and  the  canula  is  in- 
troduced, care  being  taken  that  it  is  filled  with  saline  solution. 


POST-H.KMORRIIAGIC    COLLAPSE 


873 


Next,  tie  with  a  single  knot  the  proximal  ligature  in  such  a 
manner  as  to  compress  the  vein  against  the  canula,  in  order 
to  prevent  the  escape  of  fluid,  and  remove  the  bandage  which 
was  compressing  the  arm.  Before  the  canula  is  introduced  the 
entire  apparatus  must  be  filled  with  saline  solution,  its  escape 
being  prevented  by  pressure  upon  the  tube.  The  fluid  is  now 
allowed  to  flow,  an  assistant  taking  care  that  the  funnel  is  always 
full,  and  that  no  air  gains  admission.  By  holding  the  funnel 
from  ten  to  eighteen  inches  above  the  patient,  a  sufficient 
pressure  is  obtained.  As  soon  as  the  required  quantity  of  fluid 
has  been  infused,  the  canula  is  removed,  the  vein  cut  across, 
the  second  ligature  tied  tightly,  and  the  skin  wound  closed  with 
sutures. 

Infusion  into  the  cellular  tissue  has  been  substituted  by  many 
obstetricians  and  surgeons  for  intravenous  infusion,  on  account 
of  the  greater  ease  with  which  it  is  carried  out.  Kelly,  who 
prefers  it  to  all  other  means  of  infusion,  injects  the  fluid  into 


Fig.  371. — The  Canula  introduced  into  the  Median  Vein 
just  below  the  bend  of  the  elbow. 


the  submammary  cellular  tissue.  For  this  purpose,  he  uses 
graduated  bottles  capable  of  holding  a  couple  of  pints,  to  which 
a  tube  eight  feet  in  length  is  connected.  A  long,  slender,  and 
sharp  aspirating  needle  is  fastened  to  the  other  end  of  the 
tube.  The  solution  used  is  the  same  as  for  intravenous  infusion, 
and  a  head  of  six  feet  is  required  to  make  the  fluid  run.  To 
perform  the  operation,  the  breast,  after  careful  disinfection,  is 
seized  in  the  hand  and  lifted  as  far  off  the  chest  wall  as  possible. 
The  needle,  with  the  saline  solution  flowing,  is  then  passed 
through  the  skin  at  the  base  of  the  breast  and  deeply  into  the 
connective  tissue,  taking  care  to  keep  clear  of  the  gland  structure. 
The  fluid  then  runs  in  of  its  own  accord,  and  as  soon  as  no  more 
will  flow  the  needle  is  withdrawn.  A  piece  of  adhesive  plaster 
fastened  over  the  opening  will  prevent  its  subsequent  escape. 
The  breast  will  hold  from  a  pint  and  a  half  to  two  pints,  and  the 
time  required  to  infuse  this  amount  is  about  twenty  minutes.  A 
similar  amount,  if  necessary,  can  be  infused  at  the  same  time 
under  the  other  breast.  Instead  of  into  the  breast,  the  fluid  may  be 
infused  into  the  connective  tissue  of  the  buttock,  but  the  former 
site  is  preferable. 


874  THE  PATHOLOGY  OF  LABOUR 

The  above  is  a  short  description  of  the  immediate  treatment 
necessary  in  post-haemorrhagic  collapse.  It  must  not,  however, 
be  thought  that,  as  soon  as  the  patient  has  rallied,  all  danger  is 
at  an  end.  The  resultant  enfeebling  of  the  circulation  carries 
with  it  many  dangers  from  which  she  cannot  be  regarded  as 
safe  for  a  considerable  time.  The  most  common  of  these  is  cardiac 
syncope  coming  on  at  any  attempt  at  exertion.  Pulmonary 
embolism  may  also  occur,  due  to  the  detachment  of  a  thrombus 
whose  formation  has  been  favoured  by  the  weak  action  of  the 
heart.  Crural  phlegmasia?  may  occur  from  a  like  cause,  and,  as 
happens  in  all  debilitating  conditions  of  the  patient,  the  natural 
resistance  of  the  system  to  septic  invasion  is  so  lowered  that  the 
risk  of  infection  is  greatly  increased.  In  consequence  of  the 
tendency  to  cardiac  failure,  the  patient  must  not  be  allowed  even 
to  sit  up  in  bed  during  the  first  week  or  so,  and  all  attempts  at 
raising  herself  must  be  strictly  forbidden.  The  process  of  getting 
up  must  be  a  most  gradual  one,  and,  even  after  she  is  able  to 
walk  about,  she  must  carefully  avoid  all  sudden  or  violent 
exertion.  In  order  to  promote  her  convalescence,  the  administra- 
tion of  iron  in  tolerably  large  doses  will  be  found  of  considerable 
benefit.  Careful  attention  to  the  dietary,  and  the  judicious  use 
of  stimulants,  are  also  matters  of  vital  importance. 


RETENTION  OF  THE  PLACENTA 

The  retention  of  the  placenta  in  the  uterus  after  delivery  is  one 
of  the  most  common  complications  of  labour.  In  many  cases,  if 
sufficient  time  was  allowed  to  elapse,  spontaneous  expulsion  would 
eventually  take  place,  but,  in  some  cases,  the  placenta  would  be 
retained  in  utero  indefinitely  until  perhaps  it  was  discharged  piece- 
meal in  a  sloughing  condition.  We  stated,  when  discussing  the 
management  of  the  third  stage  of  labour,  that,  if  the  uterus  did 
not  expel  the  placenta  spontaneously  within  an  hour  after  the 
birth  of  the  foetus,  steps  must  be  taken  to  cause  its  expulsion 
or  it  must  be  removed.  In  the  present  section,  we  shall  deal 
with  the  causes  of  placental  retention,  and  the  method  of  removing 
the  retained  placenta. 

Frequency. — The  manual  removal  of  the  placenta,  either  on 
account  of  the  occurrence  of  post-partum  haemorrhage  or  the 
retention  of  the  placenta  in  the  uterus  for  more  than  an  hour, 
had  to  be  performed  in  259  cases  out  of  a  total  of  20,000  labours 
at  the  Rotunda  Hospital,  a  proportion  of  one  in  77-22. 

.■Etiology. — The  chief  causes  of  placental  retention  are  insuffi- 
cient or  irregular  contractions  of  the  uterus,  dense  adhesions 
between  the  placenta  and  the  uterus,  and  abnormalities  in  the 
shape  of  the  placenta.  It  is  easy  to  understand  why  the  absence, 
or  the  insufficiency,  of  uterine  contractions  should  cause  reten- 
tion of  the  placenta,  in  the  same  manner  as  feeble  contractions 


RETENTION  OF  THE  PLACENTA  875 

fail  to  effect  the  expulsion  of  the  fcetus.  Irregular  contractions 
of  the  uterus  are  a  rarer  cause  of  retention.  In  some  cases,  the 
fibres  of  the  body  of  the  uterus  contract  circularly  below  the 
placenta,  giving  rise  to  the  so-called  hour-glass  contraction  of  the 
uterus,  and,  in  other  cases,  the  contractions  may  occur  at  the  level 
of  the  retraction  ring.  The  probable  causes  of  such  contractions 
are  the  administration  of  large  doses  of  ergot  during  the  third 
stage  of  labour,  and  the  irritation  of  the  uterine  muscle  either  by 
irregular  massage  through  the  abdominal  wall  of  the  lower  part 
of  the  uterine  body,  or  by  clumsy  efforts  to  introduce  the  fingers 
into  the  uterine  cavity.  Their  result  is  to  bring  about  an 
incarceration  of  the  placenta  above  the  area  of  contraction. 
Morbidly  dense  adhesion  between  the  placenta  and  the  uterine 
wall  is  usually  the  result  of  a  former  decidual  endometritis,  and 
is  perhaps  the  most  common  cause  of  placental  retention.  The 
principal  malformations  of  the  placenta  that  cause  its  retention 
are  a  placenta  membrancea,  which  in  consequence  of  its  want  of 
solidity  is  crumpled  up  inside  the  contracting  uterus  instead  of 
being  detached,  and  a  placenta  succenturiata  in  which  one  or 
more  of  the  detached  cotyledons  may  be  retained. 

Treatment. — In  all  cases  of  placental  retention,  unless  the 
presence  of  irregular  contractions  has  been  diagnosed,  the  first 
step  consists  in  endeavouring  to  express  the  placenta.  This  is 
done  by  seizing  the  fundus  of  the  uterus  in  the  hand  applied  over 
the  abdominal  wall  and  firmly  compressing  it  from  side  to  side 
and  from  above  downwards,  while  at  the  same  time  making  slight 
downward  pressure.  As  soon  as  the  placenta  passes  into  the 
vagina,  it  is  expressed  from  the  latter  in  the  usual  manner.  If, 
however,  irregular  contractions  are  present,  all  massage  or  friction 
of  the  uterine  wall  should  be  stopped  for  a  few  minutes,  then,  if 
the  contractions  pass  off,  expression  may  be  tried.  If  the  irregular 
contractions  do  not  pass  off,  manual  removal  of  the  placenta  must 
be  performed,  and  this  must  also  be  done  in  all  cases  in  which 
expression  fails. 

The  manual  removal  of  the  placenta  was  formerly  regarded 
as  one  of  the  most  serious  operations  in  obstetrics,  and  rightly 
so,  owing  to  the  high  rate  of  morbidity,  if  not  of  mortality,  by 
which  it  was  followed  in  consequence  of  septic  infection.  The 
operation,  if  not  carried  out  with  the  strictest  attention  to  asepsis, 
is  especially  prone  to  give  rise  to  septic  infection,  on  account  of 
the  intimate  relation  into  which  the  fingers  are  brought  with  the 
uterine  sinuses.  If,  however,  proper  precautions  are  taken,  this 
risk  can  be  very  greatly  minimised,  and,  if  rubber  gloves  are 
always  used  by  the  operator,  the  risk  is  very  small  indeed  To 
perform  the  operation,  the  patient  is  placed  in  the  dorsal  cross-bed 
position,  and,  if  necessary,  an  anaesthetic  may  be  administered. 
It  is,  however,  well  to  dispense  with  the  latter  if  possible,  as  it 
probably  weakens  the  subsequent  contractions  of  the  uterus  and 
so    favours   haemorrhage.      After    thorough    disinfection    of    the 


876 


THE  PATHOLOGY  OF  LABOUR 


external  parts,  the  hand  covered  with  a  rubber  glove  is  passed 
into  the  vagina  and  pushed  gently  upwards  in  the  form  of  a 
cone,  the  other  hand  being  placed  over  the  fundus  to  push  it 
downwards  within  reach.  If  spasmodic  contraction  of  any  part 
cf  the  uterus  offers  an  obstacle  to  the  introduction  of  the  hand, 
extreme  gentleness  must  be  used  in  passing  the  hand  through 
the  contracted  area,  as  it  is  possible  to  lacerate  the  uterus  by 
forcible  efforts  at  introduction.  If  the  hand  cannot  be  passed 
upwards,  owing  to  the  tightness  of  the  stricture,  an  anaesthetic 
must  be  administered,  and  the  spasm  will  probably  pass  off.  As 
soon  as  the  hand  has  passed  into  the  cavity,  the  fingers  feel  for 


Fig.  372. — The  Manual  Removal  of  the  Placenta. 

the  lower  edge  of  the  placenta,  and,  with  a  to-and-fro  sawing 
motion  of  their  tips,  the  placenta  is  gradually  separated  from 
below  upwards.  As  soon  as  it  has  been  completely  detached,  it 
is  grasped  in  the  fingers  and  drawn  out,  if  possible  in  a  single 
piece.  The  hand  is  then  again  introduced,  and  the  uterus  is 
examined  to  ascertain  if  any  pieces  of  placenta  or  membrane 
have  been  left  behind.  When  all  the  fragments  have  been 
removed,  the  uterus  must  be  douched  thoroughly.  During  the 
removal  of  the  placenta,  an  assistant  may  administer  a  hypo- 
dermic injection  of  ergot  in  order  to  ensure  subsequent  contrac- 
tion of  the  uterus. 


CHAPTER  X 
GENITAL  TRAUMATA 

Rupture  of  the  Uterus — Threatened  Rupture — Sudden  Rupture — Gradual 
Rupture.  Lacerations  of  the  Cervix.  Lacerations  of  the  Vagina, 
Perinaeum,  and  Vulva.  Rupture  of  the  Pelvic  Articulations.  Inversion 
of  the  Uterus. 

Genital  traumata  will  be  divided  into  the  following  groups  : — 

I.  Lacerations  of   the  supra- vaginal  portion  of   the  uterus, 
commonly  known  as  rupture  of  the  uterus. 
II.   Lacerations  of  the  infra- vaginal  portion  of  the  uterus,  i.e., 
cervical  lacerations. 

III.  Lacerations  of  the  vagina,  perineum,  and  vulva. 

IV.  Rupture  of  the  pelvic  articulations. 
V.   Inversion  of  the  uterus. 

We  shall  discuss  each  of  these  groups  separately. 


RUPTURE  OF  THE  UTERUS 

Rupture  of  the  body  of  the  uterus  is  one  of  the  most  serious 
complications  of  labour.  It  may  occur  in  any  part  of  the  body, 
though  in  practice  it  almost  always  commences  in  the  lower 
uterine  segment. 

Frequency. — It  is  difficult  to  estimate  the  frequency  of  rupture 
of  the  uterus  during  labour,  as  the  number  of  cases  which  occurs 
in  maternity  hospitals  is  greater  than  is  the  true  proportion.  The 
proportion  is  usually  stated  to  be  i  in  3,000  to  5,000,  and  accord- 
ing to  statistics  collected  in  Paris  (Jolly),  based  on  782,741 
labours,  it  is  1  in  3,403.  At  the  Rotunda  Hospital,  rupture  of 
the  uterus  occurred  ten  times  in  20,000  cases,  a  proportion  of 
1  in  2,000. 

.^Etiology. — The  causes  of  rupture  of  the  uterus  may  be  divided 
into  three  classes:  —  Obstructed  delivery;  direct  traumatism; 
degeneration  of  the  uterine  muscle. 

Obstructed  delivery  is  the  most 'common  cause.  If  the  uterus 
cannot  expel  the  foetus,  one  of  two  things  happens — either  a  con- 
dition of  secondary  uterine  inertia  supervenes,  or  rupture  of  the 

877 


878 


THE  PATHOLOGY  OF  LABOUR 


lower  uterine  segment  occurs.  In  consequence  of  prolonged  labour 
and  undue  retraction  of  the  muscle  fibres,  the  upper  uterine 
segment  becomes  progressively  thicker  and  of  smaller  capacity, 
the  lower  segment  thinner  and  of  greater  capacity,  and  eventually 
this  thinning  is  carried  to  such,  an  extent  that  the  walls  cannot 
stand  the  strain  to  which  they  are  subjected,  and  rupture  occurs. 
Such  a  rupture  may  extend  in  various  directions.  It  may  con- 
tinue upwards  into  the  thickened  fundus,  downwards  into  the 
cervix  and  vaginal  vault,  or  circularly  round  the  lower  segment. 
In  the  last  case,  the  lower  segment  may  be  completely  torn  away 
from  the  upper  segment.  A  less  common  manner  in  which 
rupture  occurs  is  by  the  attrition  or  rubbing  through  of  a  portion 
of    the   uterine   wall   which    has   become   nipped    between    the 


Fig.  373. — Diagram  representing  Approximate  Position  of  the 
Retraction  Ring  after  a  Prolonged  Labour. 

R.R.,  Retraction  ring  ;  o.i.,  os  internum  ;  o.e.,  os  externum.     (Schroeder.) 

descending  head  and  an  overhanging  sacral  promontory  or  a 
bony  exostosis.  In  these  cases,  a  hole  may  be  rubbed  in  the 
tissues,  or,  as  a  result  of  the  long-continued  pressure,  necrosis  of 
the  tissues  may  occur  and  a  fistulous  opening  form  during  the 
puerperium.  In  this  manner,  an  opening  may  be  made  into  the 
bladder  by  an  exostosis  on  the  posterior  surface  of  the  symphysis, 
or  into  Douglas'  pouch  by  the  pressure  of  the  promontory. 

Direct  traumatism,  sufficient  to  cause  rupture,  may  result  from 
any  form  of  intra-uterine  operation,  whether  manual  or  instru- 
mental. The  commonest  causes  are  perforation  of  the  uterus 
with  the  blade  of  the  forceps  or  other  instrument,  and  ill-advised 
efforts  at  internal  version  in  cases  in  which  the  degree  of  retrac- 
tion of  the  uterus  contra-indicates  such  efforts.  In  such  cases, 
rupture  usually  occurs  in  the  lower  uterine  segment. 


RUPTURE  OF  THE  UTERUS  879 

Degeneration  of  the  uterine  muscle  is  a  very  rare  occurrence, 
but  cases  of  rupture  which  have  been  proved  to  be  due  to  such  a 
cause  have  been  reported  from  time  to  time,  and  are  usually 
known  as  '  spontaneous  rupture.'  The  nature  of  the  degeneration 
varies  in  different  cases.  Jardine  ■■'■  records  a  case  in  which  '  the 
muscle  fibres  at  the  actual  seat  of  rupture  were,  for  the  most  part, 
atrophied  and  shrunken,  and  in  many  places  exhibited  transverse 
or  irregular  fractures  of  the  muscle  substance.  Nuclear  staining 
in  the  fibres  was  absent.'  In  another  case  of  spontaneous  rupture 
recorded  by  Poroschin.t  the  muscle  fibres  were  cloudy,  slightly 
outlined,  and  with  pale  nuclei ;  but  more  striking  was  the  com- 
plete absence  of  elastic  fibres,  save  in  the  walls  of  the  vessels. 
Poroschin  concluded  from  this  that  the  rupture  was  due  to  the 
absence  of  elastic  fibres.  Dakin  J  recorded  a  similar  case  in 
which  there  was  marked  fatty  degeneration  of  the  fibres.  If 
pregnancy  occurs  in  a  case  of  cancer  or  of  tuberculous  disease 
of  the  body  of  the  uterus,  rupture  may  occur  during  labour  in 
the  diseased  tissues.  As  a  rule,  however,  in  such  cases  pregnancy 
does  not  occur.  Rupture  occurring  in  cases  of  degeneration  of 
the  fibres  may  involve  any  part  of  the  uterine  wall,  and  will 
naturally  occur  at  the  site  of  maximum  structural  alteration. 
Cases  in  which  rupture  occurs  in  the  cicatrix  of  a  former 
Caesarean  section  may  be  also  included  in  this  class,  inasmuch  as 
rupture  is  due  to  the  altered  or  incompletely  formed  fibres  of  the 
scar  tissue. 

Pathological  Anatomy.  —  Rupture,  the  result  of  obstructed 
delivery,  usually  commences  in  the  lower  uterine  segment,  and 
may  extend  in  any  direction  ;  while  rupture,  the  result  of  degenera- 
tion of  the  fibres,  may  occur  at  any  part  of  the  uterus,  correspond- 
ing to  the  seat  of  maximum  degeneration  of  the  fibres.  The 
character  of  the  rupture  varies  considerably.  Usually,  it  is  an 
irregular  tear  of  varying  size,  while  in  cases  of  attrition  or  rubbing 
through  it  is  more  or  less  circular  and  accompanied  by  actual  loss 
of  tissue.  According  to  the  site,  and  the  direction  in  which  the 
rupture  extends,  the  latter  may  involve  the  part  of  the  uterus 
which  is  covered  or  uncovered  by  peritoneum.  If  it  extends 
through  the  peritoneal  investment,  it  is  known  as  a  '  complete 
rupture';  while,  if  the  peritoneal  investment  remains  intact,  or  if 
the  rupture  is  situated  below  the  line  of  peritoneal  reflexion,  it  is 
known  as  an  'incomplete  rupture.'  This  was  a  very  important 
distinction  in  pre-antiseptic  days,  when  the  great  danger  of 
rupture  was  the  extension  of  infection  from  the  uterus  to  the 
peritoneal  cavity.  Now,  however,  since  we  are  better  able  to 
maintain  uterine  asepsis,  the  relative  importance  of  the  involve- 
ment or  escape  of  the  peritoneum  is  not  so  great,  and  a  more 
important    distinction    between    ruptures    is    that    some    are   so 

*  '  Clinical  Obstetrics  '  (Rebman  and  Co.,  1903),  p.  421. 
t  Cent,  fur  Gynak.,  Feb.,  1898. 
f   Trans.  Obstct.  Soc.  Loud.,  vol.  xl. 


SSo 


THE  PATHOLOGY  OF  LABOUR 


situated  that  they  open  into  large  vessels  and  cause  profuse 
haemorrhage,  whilst  others  do  not  do  so.  Ruptures  occurring 
below  the  line  of  peritoneal  reflexion  may  extend  into  the  bladder 
or  the  anterior  or  lateral  vaginal  vaults,  or  may  involve  the 
structures  in  the  broad  ligaments.  In  the  last  case,  the  tear  may 
result  in  the  formation  of  a  haematoma  in  the  broad  ligament. 
Complete  intra-peritoneal  rupture  may  result  in  the  escape  of  the 
foetus  and  placenta  in  part  or  altogether  into  the  peritoneal  cavity, 
and  sometimes  in  profuse  intra-peritoneal  haemorrhage. 


Fig.  374. — Diagram  to  show  a  Rupture  of  the  Lower  Uterine  Segment 
in  consequence  of  the  Impaction  of  a  Hydrocephalic  Head  at  the 
Pelvic  Brim. 

H.,  Foetal  head  ;    L.S. ,  lower  uterine  segment;  U.S.,  upper  uterine  segment  ; 
R.R  ,  retraction  ring ;  a,  rent  in  lower  segment. 


Symptoms. — The  symptoms  of  rupture  of  the  uterus  depend 
mainly  upon  the  situation  and  size  of  the  rupture,  and  the  degree 
of  suddenness  with  which  it  occurs.  In  some  cases,  a  rupture  of 
large  size,  and  involving  important  bloodvessels,  occurs  with  the 
greatest  suddenness,  and  causes  correspondingly  well-marked 
symptoms ;  whilst,  in  other  cases,  the  rupture  takes  place 
gradually,  gives  rise  to  but  slight  haemorrhage,  and  consequently 
at  first  causes  no  special  symptoms.  Accordingly,  we  shall 
consider  the  symptoms  of  rupture  in  two  groups — the  symptoms 


THREATENED  RUPTURE  OF  THE  UTERUS  88 1 

of  gradual  rupture,  and  the  symptoms  of  sudden  rupture.  To 
these,  we  shall  also  add  a  third  group  —  the  symptoms  of 
threatened  rupture,  as  they  are  usually  distinct  and  well-marked. 
Threatened  Rupture. — The  symptoms  of  threatened  rupture 
have  been  already  discussed  when  dealing  with  the  symptoms  of 
unduly  prolonged  labour.*  They  consist  in  the  main  of  the 
various  signs  that  retraction  has  been  carried  farther  than  is  safe. 


Fig.  375. — Diagrammatic  Representation  of  the  Standing  Out  of  the 
Round  Ligaments  in  Threatened  Rupture  of  the  Uterus.    (Bumm.) 

The  contractions  become  very  frequent  or  sometimes  tonic,  the 
retraction  ring  rises  to  a  level  of  more  than  an  inch  and  a  half 
above  the  pubis,  the  uterus  is  tender  to  the  touch,  and  the  round 
ligaments — one  or  both — can  be  felt  as  tense  cords.  The  con- 
stitutional effect  of  the  prolonged  labour  shows  itself  in  an 
increase  in  the  rate  of  the  pulse  and  of  respiration. 
*   Vide  Part  IV.,  Chap.  II.,  p.  293. 

56 


882  THE  PATHOLOGY  OF  LABOUR 

Gradual  Rupture. — The  symptoms  that  one  would  expect  to 
find  in  gradual  rupture  are  as  follows  : — A  gradually  increasing 
collapse  of  the  patient,  due  to  haemorrhage,  with  all  the  usual 
accompanying  symptoms ;  steadily  increasing  pain  in  and  tender- 
ness of  the  abdomen ;  the  gradual  cessation  of  uterine  con- 
tractions ;  the  gradual  recession  of  the  presenting  part  if  it  is  not 
fixed  ;  a  varying  degree  of  haemorrhage  per  vaginam ;  and,  in 
cases  in  which  the  foetus  escapes  into  the  abdominal  cavity,  the 
presence  of  another  tumour  resembling  a  foetal  head  at  one  side 
of  the  false  pelvis,  and  formed  by  the  empty  uterus.  On  the 
other  hand,  the  foetus  may  be  expelled  by  the  natural  efforts, 
there  may  not  be  any  symptoms  to  call  attention  to  any  abnormal 
condition,  and  it  may  only  be  after  the  expulsion  of  the  foetus 
that  the  occurrence  of  haemorrhage  or  the  retention  of  the 
placenta — owing  to  its  escape  into  the  abdominal  cavity — shows 
that  something  abnormal  has  happened. 

Sudden  Rupture. — The  symptoms  of  sudden  rupture,  in  which 
an  extensive  tear  of  the  uterine  wall  occurs,  are  well  marked. 
The  patient  is  probably  in  the  act  of  straining  violently  in  the 
course  of  a  contraction,  when  suddenly  she  screams  out  in 
violent  pain,  and  declares  that  something  has  torn  internally. 
The  uterine  contractions,  as  a  rule,  immediately  cease,  but  the 
pain  continues.  If  the  rent  is  sufficiently  great,  a  portion  of 
or  the  whole  foetus  escapes  into  the  peritoneal  cavity,  and  the 
presenting  part — if  not  fixed — recedes  from  the  brim.  At  the 
same  time,  there  are  the  constitutional  symptoms  of  profound 
shock  : — A  weak  and  thready  pulse,  usually  very  rapid,  but  occa- 
sionally abnormally  slow ;  a  rapid  fall  of  temperature ;  and 
increased  frequency  of  respiration.  These  symptoms  are,  as  a 
rule,  due  to  the  accompanying  haemorrhage,  but  they  may  also 
be  the  result  of  profound  shock. 

Diagnosis. — The  diagnosis  of  gradual  rupture  may  be  extremely 
difficult,  inasmuch  as  there  may  not  be  anything  to  call  attention 
to  what  has  occurred.  In  cases  in  which  the  symptoms  are 
progressive,  and  mainly  due  to  haemorrhage,  the  diagnosis  has  to 
be  made  between  concealed  accidental  haemorrhage  and  rupture. 
This  ought  not  to  be  a  difficult  matter.  Concealed  haemorrhage 
sufficient  to  cause  symptoms  does  not  occur  in  the  second  stage 
of  labour  in  the  presence  of  strong  contractions.  If  the  placenta 
became  detached  in  such  a  case,  the  haemorrhage  would  either 
become  external,  or  would  be  checked  by  the  intra-uterine 
pressure.  Further,  in  concealed  haemorrhage  the  uterus  would 
increase  in  size,  whereas  in  cases  in  which  rupture  is  likely  to 
occur,  or  has  occurred,  the  previous  contractions  have  brought 
the  uterine  wall  into  close  apposition  with  the  foetus.  When  the 
foetus  escapes  into  the  peritoneal  cavity,  it  will  be  felt  more 
distinctly  by  abdominal  palpation,  inasmuch  as  it  will  be  covered 
by  the  abdominal  wall  alone  instead  of  by  the  abdominal  wall 
and  the  uterus.    The  empty  uterus  also  can  be  felt  at  one  side,  and 


THE  TREATMENT  OF  UTERINE  RUPTURES  883 

has  to  be  distinguished  in  this  position  from  the  head  of  a  second 
child  or  of  a  double  monster,  or  a  uterine  or  ovarian  tumour. 
If  the  patient  has  not  been  examined  prior  to  rupture,  it  may  be 
most  difficult  to  do  this ;  but,  if  she  has  been  examined,  the 
appearance  of  a  tumour,  which  was  not  there  at  the  commence- 
ment of  labour,  will  suggest  the  possibility  of  uterine  rupture. 
The  recession  of  the  presenting  part  will  confirm  the  diagnosis  of 
rupture,  and,  if  there  is  still  room  for  doubt,  the  end  of  a  Boze- 
mann's  catheter  may  be  passed  carefully  into  the  uterine  orifice 
and  upwards.  If  the  small  tumour  at  the  side  of  the  false  pelvis 
is  the  uterus,  the  catheter  can  be  passed  into  it. 

The  diagnosis  of  sudden  rupture  is  more  easily  made,  inasmuch 
as  the  symptoms  are  usually  very  definite.  The  feeling  of  some- 
thing having  given  way  internally,  the  sudden  cessation  of  the 
contractions,  and  the  recession  of  the  presenting  part,  are  all 
characteristic.  In  every  case,  an  exact  diagnosis  must  be  made 
after  the  delivery  of  the  foetus,  and  the  situation  and  size  of  the 
rent  be  ascertained. 

Treatment. — The  treatment  of  uterine  rupture  must  be  con- 
sidered under  two  headings — prophylactic  treatment,  and  active 
treatment. 

Prophylactic  Treatment. — The  prophylactic  treatment  of  rup- 
ture is  of  the  greatest  importance.  If,  in  all  cases  of  labour,  the 
obstetrician  watches  carefully  for  the  appearance  of  any  of  the 
symptoms  of  threatened  rupture,  and  on  their  appearance  acts  in 
accordance  with  their  indications,  rupture  will  never  occur  save 
in  the  few  isolated  cases  in  which  it  is  due  to  a  degeneration  of 
the  uterine  muscle,  of  which  it  is  impossible  to  obtain  any  fore- 
warning. 

The  first  point  in  the  prophylaxis  of  uterine  rupture  consists 
in  removing  so  far  as  possible  all  obstruction  to  the  expulsion 
of  the  foetus.  Malpresentations  of  the  latter  must  be  changed. 
Obliquities  of  the  uterine  axis  must  be  corrected,  and  the 
axis  brought  into  line  with  that  of  the  brim.  Tumours  must 
be  pushed  out  of  the  way  or  removed,  and  rigidities  of  the  soft 
parts  dilated  or  incised.  A  common  cause  of  obstruction,  and  one 
which  may  lead  to  rupture  of  the  uterus,  consists  in  the  nipping 
of  the  anterior  lip  of  an  imperfectly  dilated  cervix  between  the 
descending  head  and  the  symphysis  (v.  Fig.  376).  If  a  large  portion 
of  the  lip  is  thus  prevented  from  retracting  upwards,  it  may  form 
a  barrier  sufficient  to  prevent  the  descent  of  the  head  unless  the 
latter  carries  the  obstacle  away  before  it.  If  the  position  of  the 
lip  is  recognised  in  time,  it  can  be  easily  remedied  by  pushing  up 
the  prolapsed  portion  in  the  interval  between  the  contractions, 
and  keeping  it  up  with  the  finger  during  one  or  two  contractions. 
If  this  is  done,  the  head  will  descend,  and,  at  the  same  time,  the 
cervix  will  retract  upwards,  and  the  nipping  of  the  tissues  will 
not  recur. 

The  next  point  in  the  prophylaxis  of  uterine  rupture  consists 

56—2 


884 


THE  PATHOLOGY  OF  LABOUR 


in  the  immediate  emptying  of  the  uterus  if  any  symptoms  of 
threatened  rupture  appear,  and  in  doing  so  by  some  means  that  will 
not  increase  the  tension  of  an  already  overstrained  uterine  wall. 
Once  marked  symptoms  of  threatened  rupture  have  occurred,  all 
attempts  at  version  or  any  form  of  intra-uterine  manipulation  are 
contra-indicated.     Delivery  in  head  cases  must  be  effected  by  the 


Fig.  376. — Diagrammatic  Representation  of  Nipping  of  the  Anterior 
Lip  of  the  Cervix  by  the  Head  in  a  Case  of  Flat  Pelvis. 

A.  L.,  Anterior  lip. 


forceps  or  the  cranioclast ;  in  a  pelvic  presentation,  by  extraction 
as  a  foot  or  breech  presentation ;  and,  in  a  neglected  shoulder 
presentation,  by  decapitation  or  embryotomy.  In  almost  every 
case  in  which  marked  symptoms  of  threatened  rupture  are 
present,  the  foetus  will  have  died  as  a  result  of  the  long-continued 


THE  TREATMENT  OF   UTERINE  RUPTURES  885 

labour,  and  consequently  there  need  be  no  hesitation  in  performing 
craniotomy  if  the  condition  of  the  mother  necessitates  it. 

Active  Treatment. — The  proper  course  to  adopt  in  cases  of 
rupture  of  the  uterus  is  still  the  subject  of  considerable  difference 
of  opinion,  and,  consequently,  it  is  impossible  to  lay  down 
dogmatic  directions  to  be  followed  under  all  circumstances.  The 
first  difficulty  in  the  way  of  determining  the  correct  treatment 
lies  in  the  difficulty  of  making  an  accurate  diagnosis — not  of  the 
occurrence  of  rupture,  as  that  is  comparatively  simple,  but  of  the 
extent  of  the  rupture,  the  size  of  the  bloodvessels  which  have 
been  opened,  and  the  involvement  of  neighbouring  viscera.  The 
second  difficulty  lies  in  the  making  of  a  correct  prognosis,  or  even 
an  approximately  correct  prognosis,  as  to  how  a  particular  case 
will  terminate.  If  these  two  difficulties  are  surmounted,  there  is 
still  a  third,  that  of  carrying  out  the  treatment  indicated  under 
the  conditions  in  which  one  finds  the  patient.  These  three  diffi- 
culties make  the  question  of  the  correct  treatment  a  most  complex 
one. 

The  first  step  to  be  taken  in  any  case  of  rupture,  and  perhaps 
the  only  one  about  which  there  is  no  difference  of  opinion,  consists 
in  delivering  the  foetus,  if  it  has  not  been  already  expelled.  If 
the  foetus  is  in  the  uterus,  delivery  is  effected  through  the  vagina, 
by  the  forceps,  traction  on  the  leg,  craniotomy,  or  embryotomy. 
Under  no  circumstances  is  version  permissible,  on  account  of  the 
danger  of  increasing  the  size  of  the  rent.  Where  a  small  part  of 
the  foetus,  such  as  a  limb,  has  escaped  through  the  rent  into  the 
peritoneal  cavity,  delivery  may  still  be  effected  through  the  vagina, 
as  such  a  part  can  be  drawn  back  through  the  rent  without 
danger,  but,  where  a  considerable  portion  of  the  foetus  or  the 
whole  foetus  has  escaped,  delivery  by  the  vagina  is  impossible. 
In  such  cases,  an  immediate  coeliotomy  must  be  performed,  and 
the  foetus  extracted  through  the  opening  in  the  abdominal  wall. 

Delivery  being  effected,  we  must  next  decide  what  shall  be 
done  with  the  lacerated  uterus.  There  are  several  methods  of 
treatment  from  which  to  select  : — 

(1)  The  case  may  be  left  without  special  treatment  other  than 
the  free  administration  of  ergot,  in  the  hope  that  the  uterine 
contractions  will  close  the  rent  and  prevent  haemorrhage. 

(2)  The  uterine  and  vaginal  cavity  may  be  plugged  with 
iodoform  gauze  ;  a  firm  compress  and  tight  binder  applied  above 
the  uterus,  with  the  object  of  compressing  it  against  the  plug  ; 
and  ergot  freely  administered. 

(3)  The  rent  may  be  plugged  with  iodoform  gauze  in  order  to 
check  haemorrhage,  and  at  the  same  time  to  drain  the  peritoneal 
cavity. 

(4)  Abdominal  coeliotomy  may  be  performed  and  the  rent 
sutured. 

(5)  Abdominal  coeliotomy  may  be  performed  and  the  uterus 
removed. 


886  THE  PATHOLOGY  OF  LABOUR 

Before  discussing  these  different  methods  of  treatment,  how- 
ever, we  must  endeavour  to  determine  a  clinical  classification  of 
ruptures  based  on  the  treatment  they  require. 

From  a  purely  clinical  point  of  view,  ruptures  may  be  divided 
into  two  classes — uncomplicated  and  complicated.  By  an  uncom- 
plicated rupture,  we  mean  one  in  which  there  is  no  accompanying 
or  consequent  condition  that  calls  for  special  treatment ;  while, 
by  a  complicated  rupture,  we  mean  one  in  which  there  is  such 
an  accompanying  or  consequent  condition.  The  principal  com- 
plications which  may  be  associated  with,  or  may  result  from, 
uterine  rupture  are  the  escape  of  the  foetus  or  placenta  into  the 
peritoneal  cavity  ;  haemorrhage  ;  extension  of  the  tear  into  the 
bladder ;  prolapse  of  intestines  or  omentum  through  the  tear  in 
the  uterus  ;  and  co-existing  septic  infection  of  the  uterus. 

It  is  at  once  obvious  that  uncomplicated  and  complicated 
ruptures  differ  widely  from  one  another.  In  the  case  of  an 
uncomplicated  rupture,  we  have  solely  to  consider  what  is  the 
best  means  of  promoting  the  repair  of  the  laceration,  and  of  pre- 
venting the  occurrence  of  septic  infection ;  while,  in  a  com- 
plicated rupture,  we  have  also  to  consider  what  is  the  best 
treatment  to  be  adopted  for  the  complication,  which  sometimes 
is  more  important  than  the  rupture  itself. 

If  the.  rupture  is  uncomplicated  and  is  slight,  it  may  com- 
pletely escape  notice,  and  indeed  it  is  probable  that  such  cases 
occur  not  infrequently,  and  that  the  patient  suffers  little  or  no 
bad  effect  from  them.  If  the  rupture  is  detected,  as  sometimes  it 
may  be  during  the  manual  removal  of  a  retained  placenta,  no 
special  treatment  is  required  other  than  the  administration  of 
ergot  to  promote  contraction,  and  the  careful  watching  of  the 
patient  to  see  that  haemorrhage  does  not  occur.  If  the  rupture 
is  of  larger  size  but  is  still  uncomplicated,  it  may  be  advisable  to 
pass  a  gauze  drain  through  it  in  order  to  facilitate  the  escape  of 
any  liquor  amnii  or  other  fluid  which  may  have  found  its  way 
into  the  peritoneal  cavity.  This  drain  should  be  introduced  with 
the  most  careful  attention  to  asepsis,  and,  if  the  conditions  of  the 
case  are  such  as  to  render  asepsis  impossible,  it  is  very  much  better 
to  refrain  from  all  forms  of  active  treatment.  If  the  gauze  is 
introduced,  it  must  be  removed  in  twenty-four  hours,  and,  if  the 
patient's  temperature  is  normal,  it  need  not  be  again  introduced. 

In  complicated  ruptures,  the  treatment  depends  upon  the  nature 
of  the  complication.  Cases  in  which  the  foetus  has  escaped  into 
the  peritoneal  cavity  have  been  already  discussed.  Abdominal 
section  must  be  performed,  the  abdomen  being  opened  in  the 
middle  line  and  the  foetus  extracted.  If  no  other  complication 
is  present,  and  the  rent  is  a  clean-cut  one  and  accessible,  it 
may  be  sutured.  If  it  is  very  large  and  ragged,  it  is  probable 
that  supra-vaginal  or  complete  hysterectomy  will  have  to  be 
performed. 

In    cases  complicated  by  haemorrhage,  a  great  deal  depends 


THE  TREATMENT  OF  UTERINE  RUPTURES  887 

upon  whether  the  blood  is  escaping  into  the  uterine  or  peritoneal 
cavity.  If  the  haemorrhage  is  intra-uterine,  it  can  be  usually- 
treated  as  a  case  of  post-partum  haemorrhage.  In  such  cases, 
if  the  laceration  is  incomplete,  the  utero-vaginal  cavity  must 
be- firmly  tamponned  with  iodoform  gauze,  a  binder  and  pad 
applied  externally,  and  ergot  administered  freely.  Care  must  be 
taken  when  introducing  the  gauze  not  to  increase  the  size  of  the 
rent."  If  the  laceration  is  complete,  in  addition  to  tamponing 
the  cavity  it  is  well  to  plug  also  the  rent  itself,  in  such  a  manner 
as  to  exert  pressure  upon  the  torn  surfaces  and  thus  directly  to 
control  the  haemorrhage.  In  such  cases,  the  patient  must  be  most 
closely  watched  in  order  to  detect  at  once  the  occurrence  of  intra- 
peritoneal haemorrhage.  The  plugs  are  to  be  removed  in  twenty- 
four  hours,  and  replaced  if  there  is  any  further  haemorrhage.  If, 
however,  the  haemorrhage  is  intra-peritoneal,  the  case  is  more 
serious.  Under  such  circumstances,  there  is  no  alternative  save 
to  open  the  abdomen  and  either  suture  the  rent,  if  possible,  or 
perform  hysterectomy. 

In  cases  complicated  by  laceration  of  the  bladder  wall  and  con- 
sequent extravasation  of  urine,  the  only  hope  of  saving  the  patient 
lies  in  immediately  opening  the  abdomen  and  suturing  the  wound 
in  the  bladder.  The  uterine  tear  is  then  sutured,  or  the  uterus 
removed,  according  to  the  nature  and  position  of  the  tear. 

In  cases  complicated  by  prolapse  of  the  intestines  or  omentum 
through  the  laceration,  an  attempt  may  be  first  made  to  return 
the  prolapsed  parts  with  the  fingers  introduced  into  the  uterus. 
If  the  attempt  proves  successful  and  there  is  no  other  complica- 
tion, it  will  be  sufficient  to  plug  the  cavity  with  iodoform  gauze. 
If  the  intestines  cannot  be  returned  in  this  manner,  the  abdomen 
must  be  opened  and  the  prolapsed  part  drawn  up  from  above. 
The  laceration  is  then  sutured  or  the  uterus  removed,  as  may  be 
necessary. 

Where  a  laceration  occurs  in  a  case  in  which  there  is  pre-; 
existing  infection  of  the  uterine  cavity,  the  condition  is  most 
serious.  In  such  a  case,  infection  of  the  peritoneal  cavity  is 
certain  to  have  occurred,  and  it  is  probably  best  to  commence  by 
considering  the  case  as  one  of  general  septic  peritonitis.  Under 
such  circumstances,  the  abdomen  should  be  opened,  complete 
hysterectomy  performed,  and  the  peritoneal  cavity  drained  by 
gauze  into  the  vagina.  It  is  probable  that  thorough  flushing  out 
of  the  peritoneal  cavity  with  saline  solution  will  be  of  value.  In 
such  cases,  the  prognosis  depends  upon  the  nature  of  the  infection. 
If  it  is  of  a  virulent  character,  it  is  doubtful  if  anything  can  save 
the  patient.  If  it  is  of  a  mild  form,  she  may  be  able  to  resist  it. 
As  it  is  impossible  to  tell  beforehand  what  the  character  of  the 
the  infection  may  be,  the  case  should  be  always  considered  as 
amenable  to  treatment. 

The  foregoing  may  be  considered  to  be  an  unwise  attempt  to 
lay  dowm  too  definite  lines  of  treatment.     If,  however,  an  effort 


888  THE  PATHOLOGY  OF  LABOUR 

is  to  be  made  to  treat  uterine  rupture  with  success,  we  must  have 
some  definite  plan  which  will  furnish  us  with  the  broad  principles 
of  treatment.  If  we  have  such  a  plan,  we  shall  be  able  to  vary 
it  to  suit  the  ever-varying  complications  present,  but  without  it 
we  shall  come  to  the  treatment  of  a  particular  case  with  a  mind 
as  confused  as  the  conditions  present  are  complicated. 

Prognosis. — The  results  of  different  modes  of  treatment  can  be 
ascertained  in  a  general  way  from  statistics,  but  the  value  of 
the  latter  is  diminished  owing  to  the  difficulty  of  learning  the 
complications  and  conditions  under  which  each  case  was  treated. 
Thus,  we  can  ascertain  the  mortality  of  cases  in  which 
hysterectomy  was  performed  or  drainage  adopted,  but  it  is 
difficult  to  compare  the  relative  value  of  the  two  in  any  particular 
case,  as  the  cases  in  which  they  were  adopted  and  on  which  the 
statistics  are  based  probably  differed  considerably  from  one 
another. 

Merz*  collected  the  results  of  230  cases  of  uterine  rupture 
which  have  occurred  since  1 870,  and  tabulated  them  as  follows  : — 


Mode  of  Treatment. 

Complete  Rupture. 

Incomplete 
Rupture. 

&  0 

H  2 
<  W 

No.  of 

Cases. 

Lived. 

Percent- 
age. 

No.  of 
Cases. 

Lived. 

Per- 
cent- 
age. 

Without  special  treat  ■ 

ment 
Plugging   - 
Drainage  -         -         - 
Laparotomy     with      / 

suture    -         -         - 
Laparotomy  without  \ 

suture    -         -         -  1 
Laparotomy  (Porro)  -  ' 
Treatment  not  stated 

74 
15 
27 

24 

15 
15 
11 

12 

6 

18 

10 

8 
8 

1 

I7'5 

40 

666 

4I'7    [  .M 

53'3        * 
53'3    / 

23 
10 

7 

1 

5 

6 

3 

6 

1 

2608 
3° 
83  3 

100 

3 

Total 

181 

63 

34-8 

46 

16 

4I-3 

3 

Putting  on  one  side  the  relative  value  of  the  different  modes  of 
treatment  as  shown  by  this  table,  we  see  that  complete  rupture 
was  attended  by  a  mortality  of  65*2  per  cent.,  and  incomplete 
rupture  by  a  mortality  of  587  per  cent.  The  statistics  compiled 
by  Klein  of  Dresden,  and  based  on  an  analysis  of  381  cases,  show 
that  the  period  which  elapsed  between  the  occurrence  of  rupture 
and  operation  was  of  considerably  greater  importance  than  the 
particular  form  of  treatment  adopted.  According  to  his  statistics, 
the  total  mortality  after  operation  was  44  per  cent.  ;  and  after 
drainage,  tamponing,  or  douching,  39  per  cent.  On  the  other 
hand,  amongst  cases  operated  upon  at  home  or  in  hospital  within 

*  '  Zur  Behandlung  der  Uterusruptur,'  Archiv  f.  Gynak.,  Bd.  xlv.,  Heft  2. 


LACERATIONS  OF  THE  CERVIX 


two  hours  of  the  occurrence  of  rupture,  the  mortality  was  30  per 
cent.  ;  after  an  interval  of  from  two  to  twelve  hours,  48  per  cent.  ; 
and  after  twelve  hours,  72  per  cent. 


LACERATIONS  OF  THE  CERVIX 

Lacerations  of  the  infra-vaginal  portion  of  the  uterus,  that  is, 
of  the  cervix,  are  of  relatively  common  occurrence.  They  do 
not,  as  a  rule,  cause  any  immediate  symptoms,  and,  consequently, 
often  pass  unnoticed.  Sometimes,  however,  they  give  rise  to 
haemorrhage  and  call  for  treatment,  but  such  cases  are  rare. 

Degrees. — Clinically  three  degrees  of  cervical  laceration  are  met 
with  : — 

(1)  Laceration  of  the  first  degree  which  only  involves  the 
vaginal  portion  of  the  cervix,  and  which  does  not  give  rise  to  any 
immediate  symptoms. 

(2)  Laceration  of  the  second  degree  which  extends  sufficiently 
high  above  the  vaginal  attachment  to  involve  the  cervical  arteries, 
and  that  hence  causes  haemorrhage. 

(3)  Laceration  of  the  third  degree  which  extends  through  the 
cervix  and  vaginal  vault  into  the  peritoneal  cavity. 

^Etiology. — The  cause  of  cervical  laceration  is  the  too  rapid 
passage  of  the  foetus  through  an  imperfectly  dilated  uterine  orifice, 
and,  consequently,  anything  that  tends  to  accelerate  the  birth  of 
the  foetus,  or  that  interferes  with  dilatation  of  the  cervix,  pre- 
disposes to  the  occurrence  of  lacerations.  The  too  rapid  expulsion 
of  the  foetus  may  be  caused  by  unduly  strong  contractions,  or  by 
too  energetic  traction  with  the  forceps ;  while  imperfect  dilatation 
of  the  uterine  orifice  may  be  due  to  extraction  during  the  first 
stage  of  labour,  to  any  of  the  conditions  that  cause  stenosis  of  the 
cervix,  or  to  spasmodic  contraction  of  the  cervix.  The  nipping 
of  the  anterior  lip  of  the  cervix,  to  which  reference  has  been 
already  made,  is  also  a  cause  of  cervical  laceration. 

Symptoms. — The  first  degree  of  cervical  laceration  rarely  causes 
any  symptoms.  Occasionally,  it  may  involve  a  vessel  that  is 
larger  than  usual,  and  haemorrhage  result.  The  second  degree 
of  laceration  usually  gives  rise  to  haemorrhage,  but  here  again 
exceptions  may  occur.  Laceration  of  the  third  degree  usually 
gives  rise  to  haemorrhage,  and,  if  extensive,  may  allow  the  descent 
of  a  portion  of  intestine  or  omentum  through  the  tear  into  the 
vagina.  As  a  rule,  in  these  cases  the  rent  extends  through  the 
posterior  fornix  into  Douglas'  pouch.  Sometimes,  it  involves  the 
lateral  fornices,  in  which  case  the  uterine  arteries  may  be  torn. 

Diagnosis. — As  has  been  mentioned,  cervical  laceration  will 
escape  notice  unless  it  gives  rise  to  haemorrhage,  or  unless  a 
vaginal  examination  is  made,  for  some  other  reason,  as  a  retained 
placenta,  and  the  condition  discovered.  If  haemorrhage  occurs 
from  a  laceration,  it  is  termed  traumatic  haemorrhage,  and  the 


890  THE  PATHOLOGY  OF  LABOUR 

method  of  distinguishing  it  from  atonic  haemorrhage  has  been 
already  discussed. *  The  existence  of  a  laceration  extending  into 
the  peritoneal  cavity  is  ascertained  by  making  a  careful  examina- 
tion. 

Treatment.  —  Laceration  of  the  cervix  of  the  first  or  second 
degree  that  causes  haemorrhage  must  be  sutured.  The  method 
of  doing  so  will  be  described  later,  t  Laceration  of  the  third 
degree  extending  into  the  peritoneal  cavity  must  be  treated  on 
the  same  lines  as  is  uterine  rupture. 


LACERATIONS  OF  THE  VAGINA,  PERINEUM,  AND 

VULVA 

Lacerations  of  the  vagina,  vulva,  or  perinaeum  are  the  most 
common  injuries  which  occur  to  the  genital  tract  as  a  result  of 
labour.  Frequently,  they  are  associated,  and  almost  every  lacera- 
tion of  the  perinaeum  that  requires  suturing  is  accompanied  by  a 
corresponding  tear  of  the  vagina.  Vaginal  lacerations,  however, 
may  occur  quite  independently  of  perinatal  lacerations,  and  vulvar 
laceration  may  occur  independently  of  either.  Consequently,  we 
shall  discuss  the  three  kinds  separately. 

Laceration  of  the  Vagina. — Traumata  of  the  vagina  may 
occur  in  two  distinct  forms.  Most  commonly,  they  occur  as 
lacerated  wounds  due  to  the  overstretching  of  the  mucous  mem- 
brane, and  extending  a  varying  distance  into  the  peri-vaginal 
structures.  More  rarely,  they  occur  as  fistulous  openings,  the 
result  of  long-continued  compression  of  the  parts  between  the 
head  and  the  bony  pelvis.  In  these  cases,  the  compression 
causes  necrosis  of  the  tissues,  sloughing  usually  occurs,  the  piece 
of  necrosed  tissue  comes  away,  and  an  opening  is  left  between 
the  vagina  and  a  neighbouring  organ,  or  leading  into  the 
surrounding  connective  tissue. 

Symptoms. — The  symptoms  of  lacerations  of  the  vaginal  mucous 
membrane  are  usually  slight.  If  a  bloodvessel  is  involved,  there 
will  be  a  varying  degree  of  traumatic  haemorrhage  according  to 
the  size  of  the  vessel,  but,  as  a  rule,  there  is  little  haemorrhage. 
Wounds,  the  result  of  long-continued  compression,  if  they  are 
infected  and  slough,  will  give  rise  to  a  putrid  discharge,  which 
comes  on  from  two  to  five  days  after  delivery,  and  is  associated 
with  a  rise  of  temperature.  On  inspection,  they  appear  as  grey 
sloughing  areas.  If  they  are  situated  on  the  anterior  or  posterior 
vaginal  wall,  the  bladder  or  rectum  may  be  involved  and  a  vesico- 
vaginal or  recto-vaginal  fistula  result,  while,  if  they  are  near  the 
vaginal  vault,  the  ureter  may  be  opened  and  a  uretero-vaginal 
fistula  form.  Vesico-  or  uretero-vaginal  fistulas  cause  incontinence 
of  urine,  recto-vaginal  fistulas  incontinence  of  faeces  and  flatus. 

*    Vide  Part  VII.,  Chap.  IX.,  p.  860.  -j-   Vide  Part  IX.,  Chap.  I. 


LACERATIONS  OF  THE  PERINEUM  891 

Diagnosis. — The  lower  part  of  the  vagina  in  the  region  of  the 
perinaeum  should  always  be  examined  after  delivery  to  ascertain 
if  laceration  has  occurred.  The  existence  of  lacerations  of  the 
upper  part  of  the  vagina  will  only  be  detected  if  the  occurrence 
of  haemorrhage  or  retention  of  the  placenta  leads  us  to  make  a 
vaginal  examination.  Later  on,  the  appearance  of  symptoms  of 
sapraemic  infection  associated  with  a  putrid  discharge,  or  the 
involuntary  escape  of  urine,  may  lead  to  the  discovery  of  hitherto 
unnoticed  lacerations  or  necrosed  areas.  If  slight  bleeding 
precedes  the  birth  of  the  head,  it  will  usually  be  found  to  come 
from  a  vaginal  laceration. 

Treatment.  —  Vaginal  lacerations,,  which  are  recognised  im- 
mediately after  delivery,  should  be  sutured,  as  in  the  case  of 
a  lacerated  perinaeum,  with  the  object  of  preventing  infection 
of  the  wound  surface.  If,  however,  they  are  not  discovered 
until  infection  has  occurred,  the  treatment  consists  in  careful 
vaginal  douching,  and  the  application  of  iodoform  dusted  on 
in  the  form  of  powder  or  introduced  into  the  vagina  as  bougies 
or  on  iodoform  gauze.  The  treatment  of  fistulae  belongs  to  the 
domain  of  gynaecology  and  will  not  be  here  discussed. 

Lacerations  of  the  Perineum.— Lacerations  of  the  perinaeum 
are  of  more  frequent  occurrence  and  of  greater  importance  than 
simple  vaginal  lacerations. 

Degrees. — We  shall  divide  lacerations  of  the  perinaeum  into  two 
groups  according  to  their  degree  :  — 

(1)  Incomplete  laceration,  in  which  the  laceration  is  limited  to 
the  perinaeal  body   and  does  not  extend  into  the  rectum.* 

(2)  Complete  laceration,  in  which  the  laceration  extends 
through  the  perinaeal  body  into  the  rectum. 

Either  of  these  groups  may  be  '  superficial '  or  deep,  according 
as  they  only  involve  the  perinaeal  skin  and  superficial  perinaeal 
fascia,  or  extend  more  deeply  in  the  direction  of  the  deep  perinaeal 
fascia. 

In  another  classification  of  perinaeal  lacerations  three  degrees 
are  recognised  : — A  first  degree  where  the  tear  involves  only  the 
anterior  half  of  the  perinaeum  ;  a  second  degree  in  which  the 
laceration  extends  through  the  perinaeal  body  as  far  as  the  external 
sphincter,  but  does  not  involve  that  muscle ;  and  a  third  degree  in 
which  the  laceration  extends  through  the  sphincter  and  the  rectal 
wall.  As,  however,  the  first  degree  is  of  no  practical  impor- 
tance, this  classification  differs  little  from  the  former. 

The  depth  of  the  laceration,  i.e.,  the  distance  it  extends  upwards, 
varies  considerably.  In  some  cases,  the  tear  involves  little  more 
than  the  skin  and  the  immediately  subjacent  tissues.  In  other 
cases,  it  extends  more  deeply,  and,  in  addition  to  involving  the 
skin,  the  vaginal  mucous  membrane  is  also  torn  for  a  considerable 
distance.  In  other  cases,  again,  the  skin  may  be  but  very  slightly 
*  Vide  illustrations  in  Part  IX.,  Chap.  I. 


892  THE  PATHOLOGY  OF  LABOUR 

involved,  while  the  vaginal  mucous  membrane  and  the  deeper 
parts  of  the  perinaeal  body  are  extensively  torn.  The  vaginal 
tear  is  seldom  median,  but  as  a  rule  is  situated  to  one  side  of  the 
median  raphe,  or  may  involve  both  sides. 

A  curious  form  of  laceration,  which  sometimes  occurs,  is  that 
known  as  central  rupture  of  the  perinaeum.  In  this,  the  laceration 
involves  neither  the  posterior  commissure  nor  the  rectal  wall,  and 
is  of  the  nature  of  a  button-holing  of  the  perinaeal  body.  If  the 
vulvar  orifice  is  very  small  the  entire  foetus  may  pass  through 
the  opening  thus  made.  * 

^Etiology. — The  cause  of  perinaeal  laceration  is  the  over- 
distension of  the  parts  during  the  expulsion  of  the  foetus.  Lacera- 
tions usually  occur  during  the  expulsion  of  the  head,  but  may 
also  occur  during  the  birth  of  the  shoulders.  They  are  rarely 
met  with  in  multipara,  but  may  occur  during  the  birth  of  an 
unusually  large  foetus. 

Symptoms. — The  immediate  symptoms  caused  by  a  perinaeal 
rupture  are  slight,  as  it  is  very  rare  for  a  vessel  to  be  involved 
which  is  large  enough  to  cause  haemorrhage.  The  late  symptoms, 
i.e.,  the  symptoms  that  appear  during  the  puerperium,  may  be 
more  marked.  If  the  laceration  is  complete,  incontinence  of  faeces 
and  flatus  results  as  soon  as  a  purgative  is  administered.  If  the 
torn  surfaces  become  infected,  puerperal  ulcers  form  just  as  in  the 
case  of  the  sloughing  of  a  vaginal  tear,  and  these  give  rise  to  a 
sanious  discharge  and  the  usual  symptoms  of  sapraemic  intoxica- 
tion. The  remote  symptoms,  that  is,  those  coming  on  weeks  or 
months  after,  are  consequent  upon  the  weakening  of  the  pelvic 
floor,  and  the  vaginal  gaping  which  results  from  the  shortening  of 
the  perinaeum.  The  most  serious  consequence  of  perinaeal  lacera- 
tions is  the  weakening  of  the  pelvic  floor,  and  the  resultant  tendency 
to  prolapse  of  the  uterus.  This  weakening  is  due  to  the  tearing 
across  of  one  or  both  sides  of  the  levator  ani  muscle,  which,  as  we 
have  already  seen,  is  one  of  the  principal  structures  in  the  pelvic 
floor.  It  is  not  too  much  to  say  that  one  of  the  most  important 
factors  in  the  causation  of  gynaecological  complaints  is  a  neglected 
laceration  of  the  perinaeum  and  levator  ani  muscle. 

Diagnosis. — The  diagnosis  of  perinaeal  laceration  is  readily  made 
by  inspection  of  the  parts  immediately  after  the  foetus  is  born. 
The  obstetrician  gently  separates  the  labia  with  aseptic  fingers 
and  wipes  away  any  blood  that  may  obscure  his  view.  The 
perinaeum  is  then  seen,  and  any  lacerations  are  at  once  visible. 
To  determine  how  far  a  laceration  extends  up  the  vagina,  the 
finger  must  be  introduced,  and  then  the  gap  in  the  smooth  vaginal 
mucous  membrane  will  be  readily  detected.  It  is  surprising  how 
frequently  in  the  past  medical  men  have  stated  that  they  have 
never  met  with  lacerations  of  the  perinaeum  in  their  practice,  and 
invariably  in  such  cases  they  also  confess  that  they  have  never 

*  For  a  bibliography  of  such  cases,  vide  Spiegelberg's  'Midwifery,'  New 
Sydenham  Society's  edition,  vol.  ii.,  p.  309. 


LACERATIONS  OF  THE  VULVA  893 

looked  for  them.  '  It  cannot  be  too  clearly  stated  that  perinaeal 
lacerations  very  frequently  occur  in  primiparae,  and  occasionally 
in  multiparas.  If  the  patient  is  confined  in  the  usual  lateral 
position,  and  the  buttocks  are  uncovered- — as  should  invariably 
be  done — during  the  expulsion  of  the  foetus,  the  occurrence  of  the 
laceration  can  usually  be  seen.  Sometimes,  however,  especially 
when  the  laceration  occurs  during  the  expulsion  of  the  shoulders, 
its  occurrence  may  not  be  detected  during  birth,  and  consequently 
in  all  cases  a  visual  examination  of  the  parts  must  be  made  after 
the  birth  of  the  foetus. 

Treatment. — The  treatment  of  laceration  of  the  perinaeum  may 
be  summed  up  in  the  words  of  Spiegelberg*  : — '  Every  tear,  even 
the  smallest,  should  be  sewn  up,  partly  because  the  proceeding  is 
simple  and  but  little  painful,  partly  because  spontaneous  union  is 
almost  always  imperfect,  while,  on  the  other  hand,  the  perinaeum 
can  never  form  a  proper  pelvic  floor  unless  it  regain  its  original 
form.'  Small  tears  should  be  sutured,  as,  if  they  are  left  to 
granulate,  they  may  form  the  seats  of  puerperal  ulcers  ;  while 
large  tears  predispose  to  prolapse.  The  method  of  suturing  will 
be  discussed  subsequently.  The  operation  in  the  case  of  superficial 
and  incomplete  lacerations  is  best  performed  immediately  after  the 
foetus  is  expelled.  At  this  time,  the  patient  is  still  partly  under  the 
influence  of  an  anaesthetic — if  one  has  been  administered  during 
labour,  and,  even  if  she  has  not  been  anaesthetised,  the  bruising 
which  the  parts  have  undergone  render  them  comparatively 
insensitive.  If,  however,  we  are  dealing  with  deep  or  complete 
lacerations,  in  which  two  or  three  different  sets  of  sutures  may  be 
required — according  as  the  vaginal  and  rectal  mucous  membrane 
are  implicated,  an  anaesthetic  must  usually  be  given  to  the  surgical 
degree  after  the  expulsion  of  the  placenta,  and  the  lacerations 
sutured.  There  is,  of  course,  some  slight  risk  in  suturing  the 
perinaeum  even  in  superficial  laceration  prior  to  the  expulsion  of 
the  placenta,  as  in  some  cases  the  manual  removal  of  the  latter 
may  be  necessary,  a  proceeding  which  might  necessitate  the 
removal  and  re-introduction  of  the  sutures,  lest  they  should  be 
torn  out.  This  risk  is  not,  however,  of  sufficient  importance  to 
deter  us  from  suturing  the  perinaeum  prior  to  the  expulsion  of  the 
placenta,  as  the  advantages  of  so  doing  more  than  counterbalance 
it.  The  manual  removal  of  the  placenta  is  very  rarely  required 
in  primiparae,  and  it  is  in  their  case  that  lacerations  most  usually 
occur.  Further,  even  if  it  is  required,  the  removal  of  the  sutures 
is  accomplished  in  a  moment,  and  the  pain  of  re-introduction  is  no 
greater  than  if  their  introduction  had  been  postponed  until  after 
placental  expulsion. 

Lacerations  of  the  Vulva. — Lacerations  of  the  vulva,  other 
than  those  occurring  in  the  neighbourhood  of  the  perinaeum,  are 
extremely  rare,  and  when  they  do  occur  are  usually  of  no  im- 
*  Op.  cit.,  vol.  ii . ,  p.  311. 


894  THE  PATHOLOGY  OF  LABOUR 

portance.  In  some  cases,  however,  lacerations  may  be  found  in 
the  neighbourhood  of  the  clitoris,  and  may  involve  the  plexus  of 
veins  that  surround  that  part,  and  in  these  cases  profuse  traumatic 
haemorrhage  may  result.  The  diagnosis  of  such  cases  has  been 
discussed  under  the  head  of  post-partum  haemorrhage. 

Treatment. — Lacerations  about  the  clitoris,  if  deep,  or  if  causing 
haemorrhage,  must  be  sutured,  as  has  been  described  when  dis- 
cussing traumatic  post-partum  haemorrhage. 


RUPTURE  OF  THE  PELVIC  ARTICULATIONS 

Rupture  of  the  pelvic  articulations  is  a  very  rare  accident.  It 
most  usually  occurs  at  the  symphysis,  and  is  due  to  the  forcible 
separation  of  the  pubic  bones.  It  is  always  associated  with  over- 
straining or  separation  of  one  sacro  iliac  articulation,  as  the  rigid 
pelvic  ring  will  only  open  up  if  two  points  at  least  on  its  circum- 
ference are  loosened  (Spiegelberg*).  According  to  the  same 
author,  the  symphysis  and  the  right  sacro-iliac  joint  are  most 
usually  torn,  next  the  symphysis  and  the  left  sacro-iliac  joint, 
then  all  three  joints,  and  most  rarely  of  all  the  two  sacro-iliac 
joints  alone. 

/Etiology. — The  predisposing  causes  of  rupture  are  to  be  found 
in  previous  inflammation  or  relaxation  of  the  joint.  In  such  cases, 
a  very  small  degree  of  pressure  may  cause  rupture.  Ahlfeldt 
records  a  case  in  which  the  pelvic  articulations  ruptured  during 
labour,  although  the  foetus  was  expelled  within  an  unruptured 
bag  of  membranes — a  fact  which  showed  that  the  intra-uterine 
pressure  could  not  have  been  excessive.  In  cases  in  which  there 
is  no  apparent  antecedent  disease,  rupture  may  be  due  to  dispro- 
portion between  the  head  and  the  pelvis,  associated  with  strong 
uterine  action.  It  may  also  occur  from  too  forcible  attempts  at 
extraction  with  the  forceps,  in  cases  in  which  the  head  is  too  large 
to  pass  through  the  pelvis.  Rupture  is  most  common  in  cases  of 
generally  contracted  pelvis,  owing  to  the  forcible  thrusting  apart 
of  the  innominate  bones  at  each  end  of  the  narrowed  transverse 
diameter.  Rupture  is  also  common  in  osteomalacic  pelves,  as, 
in  them,  transverse  contraction  is  associated  with  softening  of  the 
joints. 

Diagnosis.  —  The  patient  may  in  some  cases  give  a  definite 
history  of  having  heard  and  felt  the  joint  rupture.  Then,  on 
palpation,  the  ruptured  joint  is  found  to  be  painful  and  tender, 
and  the  patient  is  unable  to  move  the  legs,  which  are  rotated 
outwards  on  the  hip-joints  (Ahlfeld).  In  rupture  of  the  symphysis, 
pain  can  also  be  elicited  by  pressure  on  its  posterior  surface  with 
the  finger  in  the  vagina.  In  rupture  of  the  sacro-iliac  joint,  pain 
is  elicited  by  gently  pressing  together  the  crests  of  the  ilia. 

*  Op.  cit.,  vol.  ii..,  p.  322. 

■j-  'Die  verletzungen  der  Beckengelenke,'  etc.  Schmidt's  Jahrbuch,  Bd. 
clxix,  1876. 


INVERSION  OF  THE   UTERUS  895 

Treatment. — The  treatment  is  identical  with  that  of  cases  in 
which  symphysiotomy  has  been  performed.  The  patient  must 
remain  in  the  horizontal  position,  with  the  pelvic  bones  maintained 
in  their  proper  position  by  means  of  a  binder,  until  such  time  as 
union  has  been  obtained,  and  even  after  she  is  able  to  walk  the 
binder  must  be  continued  for  at  least  a  year. 


INVERSION  OF  THE  UTERUS 

When  the  form  of  the  uterus  is  so  altered  that  the  inner 
surface  of  the  organ  is  turned  outwards  and  the  outer  surface  is 
turned  inwards,  the  uterus  is  said  to  be  inverted.  This  form  of 
uterine  displacement  is  met  with  either  as  an  acute  inversion 
occurring  immediately  after  delivery,  or  as  a  chronic  inversion. 
Here,  we  are  alone  concerned  with  the  acute  form. 

Frequency. — Inversion  of  the  puerperal  uterus  is  a  rare  accident. 
Churchill  stated  that  it  had  occurred  only  once  in  190,000 
deliveries  in  the  Rotunda  Hospital,  but  we  doubt  that  this  is 
even  an  approximately  correct  proportion.  We  have  ourselves 
met  with  one  case  in  the  Extern  Department  of  the  Rotunda 
Hospital,  and  Purefoy  showed  before  the  British  Gynaecological 
Society  other  cases  which  had  occurred  during  his  Mastership. 

Degrees. — Schultze  describes  three  degrees  of  inversion.  They 
are  as  follows  : — 

(1)  The  first  degree  comprises  those  cases  in  which  the  inverted 
fundus  lies  at  or  above  the  os  externum.  This  degree,  which  is 
the  initial  stage  of  all  inversions,  is  rarely  permanent,  as  it  tends 
either  to  become  reduced,  or  else  to  continue  and  pass  into  one 
of  the  succeeding  degrees. 

(2)  The  second  degree  includes  those  cases  in  which  the 
fundus  has  passed  lower  down,  and  in  which  more  or  less  of  the 
inverted  uterus  lies  below  the  external  os.  It  is  the  degree  in 
which  chronic  inversion  is  most  usually  met. 

(3)  The  third  degree  comprises  those  cases  in  which  the  entire 
uterus,  including  the  cervix,  has  become  inverted.  It  is  very 
rarely  met  with  in  cases  of  chronic  inversion,  but  an  acute  inver- 
sion is  probably  usually  found  in  this  condition. 

JEtiology. — Three  conditions  must  be  associated  in  order  to 
permit  of  the  occurrence  of  either  the  second  or  third  degree  of 
inversion  (Schultze).  These  are  : — Enlargement  of  the  cavity  of 
the  uterus ;  relaxation  of  part  of  its  wall ;  and  a  cervix  which  is 
sufficiently  dilated,  or  capable  of  being  sufficiently  dilated,  to  allow 
the  passage  of  the  body  of  the  uterus.  All  these  conditions  are 
fulfilled  after  delivery  in  those  cases  in  which  the  uterus  does 
not  contract  well.  With  these  conditions  present,  if  the  intra- 
uterine pressure  becomes  less  than  the  intra-abdominal  pressure 
the  fundus  dimples  in,  and,  if  this  relation  between  the  two 
pressures  is  continued,  inversion   goes  on    until    it   has  become 


896  THE  PATHOLOGY  OF  LABOUR 

complete.  Accordingly,  all  factors  which  cause  such  a  relation 
between  the  two  pressures  may  be  regarded  as  the  exciting  causes 
of  inversion.     The  more  important  of  these  are  : — 

(1)  Dragging  upon  the  placental  site,  in  the  case  of  a  fundal 
insertion  of  the  placenta,  by  pulling  upon  the  cord  while  the 
placenta  is  still  adherent. 

(2)  Violent  straining  associated  with  sudden  emptying  of  the 
uterus,  as  : — precipitate  labour  ;  or  severe  straining  and  pressure, 


Fig.  377.  — Complete  Inversion  of  the  Uterus  and  Vagina,  the 
Placenta  still  adherent. 

V,  Vagina;  O,  uterine  orifice.     (Bumm.) 


in  the  removal  of  the  placenta,  while  the  uterus  is  in  a  relaxed 
condition  (Winckel). 

Symptoms.  —  The  occurrence  of  acute  inversion  is  usually 
marked  by  the  collapse  of  the  patient,  a  collapse  which  may  come 
on  either  immediately  after  inversion  occurs,  or  more  rarely  after 
a  few  hours.  If  the  placenta  has  been  separated  in  part  or 
altogether,  there  will  also  be  severe  haemorrhage. 

Diagnosis. — If  the  hand  is  placed  upon  the  abdominal  wall, 
the  absence  of  the  fundus  of  the  uterus  from  its  usual  position 


INVERSION  OF  THE  UTERUS  897 

will  be  readily  determined.  If  a  careful  bi-manual  examination 
is  made,  it  may  be  possible  to  determine  the  existence  of  a  cup- 
shaped  depression  corresponding  more  or  less  exactly  to  the 
former  position  of  the  cervical  canal.  At  the  same  time,  the 
vagina  is  found  to  be  occupied  by  a  globular  tumour  to  which 
the  placenta  may  or  may  not  be  attached,  or  in  extreme  cases  the 
vagina  may  be  also  partially  or  completely  inverted,  and  so  the 
inverted  uterus  may  lie  in  part  or  altogether  outside  the  vulva. 
The  diagnosis  is  then  at  once  obvious.  If  the  inversion  is  only 
partial,  a  cup-shaped  depression  will  be  felt  in  the  centre  of  the 
uterus. 

Treatment. — The  treatment  consists  in  the  detachment  of  the 
placenta,  the  replacement  of  the  uterus,  and  the  adoption  of 
measures  calculated  to  keep  the  latter  in  its  normal  position. 

There  is  nothing  special  to  be  said  regarding  the  removal  of 
the  placenta,  and  it  is  carried  out  in  the  ordinary  manner,  the 
greatest  care  being  taken  to  ensure  asepsis.  The  replacement 
of  the  uterus  in  acute  cases  is  not  usually  a  very  difficult  matter. 
The  uterus  is  grasped  in  the  hand,  and  pushed  gently  upwards, 
endeavouring  to  return  first  the  part  that  came  down  last.  If 
the  size  of  the  uterus  prevents  its  reduction,  it  is  possible  that 
the  proceeding  would  be  facilitated  by  producing  a  temporary 
partial  anaemia  of  the  uterus  by  the  application  of  adrenalin, 
and  so  a  temporary  reduction  in  the  size  of  the  uterus.  At  any 
rate,  adrenalin  might  be  tried,  as,  if  used  in  a  sterile  condition, 
it  could  cause  no  harm  and  might  prove  of  value. 

As  soon  as  the  uterus  has  been  replaced,  it  is  douched  out 
thoroughly,  and  plugged  firmly  with  iodoform  gauze  with  the 
object  of  preventing  the  recurrence  of  the  displacement. 

Prognosis. — An  acute  inversion,  if  left  untreated,  is  frequently 
fatal.  If  ithe  patient  survives,  it  passes  into  the  chronic  stage. 
If  the  condition  is  recognised,  and  treated  before  the  patient  has 
lost  an  excessive  quantity  of  blood  and  before  the  uterine  cavity 
has  become  infected,  the  prognosis  is  fairly  good. 


57 


PART   VIII 
PATHOLOGY    OF    THE    PUERPERIUM 


57—2 


CHAPTER  I 
THE  SURGICAL  FEVERS  OF  CHILDBED 

Introduction — Nomenclature — iEtiology  ;  The  Infecting  Organisms  ;  Pre- 
disposing Causes — Sapraemia — Local  Septic  Infection — General  Septic 
Infection  ;  Lymphatic  Sepsis  ;  Pyaemia. 

There  is  no  question  as  to  the  supreme  importance  to  the 
obstetrician  of  the  group  of  diseases  formerly  known  as  '  Puer- 
peral Fever,'  and  still  written  of  in  Germany  as  '  Kindbettfiebe.r ' 
— the  fever  of  childbed.  Records  of  puerperal  mortality  and 
morbidity  still  demonstrate  clearly  enough  how  little  removed 
from  being  pathological  are  such  physiological  crises  as  labour 
and  childbed.  A  little  more  than  twenty  years  ago  Winckel, 
basing  his  conclusions  on  717,000  hospital  and  362,000  private 
cases,  could  affirm  that  the  mortality  from  all  causes  averaged 
3  per  cent,  in  the  former  and  o*6  to  0-7  per  cent,  in  the  latter, 
and  the  greater  part  of  this  mortality  must  be  credited  to 
puerperal  fever.  These  statistics  belonged,  of  course,  to  the  pre- 
antiseptic  period  ;  and,  if  the  statistics  of  to-day  no  longer  cast 
so  deep  a  shadow  on  the  usefulness  of  our  art,  they  suffice  to 
show  how  far  we  still  are  from  the  attainment  of  the  obstetric 
ideal — a  truly  physiological  labour. 

In  a  recent  text-book,  Bumm  of  Halle  begins  his  lecture 
on  '  Kindbettfieber  '  by  the  statement : — '  The  pathology  of 
childbed  is  dominated  by  puerperal  fever.  Only  the  fourth  part 
of  the  women  who  die  as  a  result  of  labour  do  so  in  consequence 
of  such  special  complications  as  eclampsia,  ruptured  uterus, 
haemorrhage,  embolism,  or  of  such  accidental  diseases  as  occa- 
sionally attack  a  woman  during  childbed.  Three-fourths  of  the 
mortality  is  due  to  puerperal  fever.'  This,  be  it  noticed,  is  the 
opinion  of  an  expert,  in  a  country  where  many  causes  combine  to 
make  statistics  of  more  value  than  they  are  among  us.  Yet  our 
own  statistics  suffice  to  teach  us  important  lessons.  Byers,  of 
Belfast,  has  collected  some  useful  statistics  in  relation  to  present- 
day  puerperal  mortality  in  Ireland,  which  show  that,  among 
7,603  patients  of  the  Rotunda  Lying-in  Hospital  during  the  two 
years  ending  November  1,  1903,  there  were  eight  deaths  from 
sepsis— representing  a  mortality  of  o'i  per  cent.     On  the  other 

901 


902  PATHOLOGY  OF  THE  PUERPERIUM 

hand,  the  general,  as  distinguished  from  hospital,  mortality  from 
the  same  cause  is  given  as  0-233  Per  cent,  in  1900,  0-228  in  1901, 
0-216  in  1902,  and  0-231  in  1903."  Here,  then,  we  have  a  very 
striking  contrast  with  the  state  of  things  as  indicated  by 
Winckel's  statistics.  First,  we  note  the  marked  improvement 
in  both  classes  of  cases,  an  improvement  most  marked  among 
hospital  patients ;  and,  secondly,  we  note  that  the  puerperal 
mortality,  arising  from  the  causes  we  are  discussing,  is  now  dis- 
tinctly less  in  well-managed  hospitals  than  that  occurring  in  con- 
nection with  privately  conducted  labour  cases,  and  this  despite 
the  prima  facie  disadvantages  and  risks  attending  the  accumula- 
tion of  patients  in  a  hospital  used  for  clinical  instruction. 

How  far  habitual  expert  pathological  opinion  upon  fatal  cases 
might  tend  to  increase  the  percentages  as  here  presented  to  us  is 
an  open  question.  It  seems  probable  to  the  writer  that — to  a 
much  greater  extent  here  than  in  Germany — such  statistics  must 
be  regarded  as  giving  as  favourable  a  return  as  circumstances 
permit,  especially  in  the  case  of  the  non-hospital  statistics.  It 
must  be  considered  that  twenty-five  years  ago,  at  a  time  not  far 
removed  from  that  of  Meigs  in  America,  who  attributed  these 
diseases  to  the  action  of  '  chance  or  Providence,'  and  when 
authorities  of  our  own,  following  Fordyce  Barker,  regarded  them 
as  effects  of  '  epidemic  constitution,'  there  was  no  such  reason  as 
undoubtedly  exists  at  present  for  avoiding  in  death  certificates 
the  use  ofj  a  term  which  is  apt  to  convey  a  suggestion  of  personal 
responsibility. 

Nomenclature.  —  In  the  foregoing  paragraphs  the  old  term 
'  puerperal  fever,'  by  which  the  diseases  here  treated  of  were 
once  universally  known,  has  been  used.  It  is,  however,  an 
example  of  a  very  inadequate  nomenclature,  suggesting,  in  one 
sense,  the  existence  of  a  specific  fever  essential  to  childbed ;  or 
in  another,  the  simple  fact  of  fever,  whatever  its  kind,  existing 
during  this  period  ;  while,  in  a  third  sense,  the  term  has  been 
limited  in  its  use  to  the  graver  and  more  fatal  forms  of  fever  which 
may  arise  during  childbed.  For  adhering  to  its  first,  and,  from 
a  verbal  point  of  view,  only  legitimate  sense,  there  never  were 
sufficient  grounds,  while  the  progress  of  bacteriological  knowledge 
has  rendered  it  entirely  untenable.  Individual  cases  vary  so 
greatly  in  symptoms,  signs,  and  microscopic  and  macroscopic 
pathology,  that  it  is  no  longer  possible  to  allege  the  existence 
of  any  fever  essentially  connected  with  the  puerperal  state.  In 
the  second  sense,  it  might,  perhaps,  be  replaced  by  the  term 
'  puerperal  fevers,'  as  has  been  done  by  Galabin,  if  it  were  not 
that  scientific  nomenclature  demands,  where  possible,  that  we 
should  prefer  the  use  of  some  term  or  terms  which  would  serve 
the  purpose  of  informing  us  as  to  the  true  nature  of  the  disease. 
In  the  third  sense  is  contained  an  assumption,  entirely  unsup- 

*   Vide  also  Part  IV.,  Chap.  II.,  p.  296. 


THE  SURGICAL  FEVERS  OF  CHILDBED  903 

ported  by  evidence,  that  there  is  a  fundamental  difference  in  kind 
between  such  fevers  as  are  dangerous  and  such  as  are  not. 

Despite,  then,  the  advantages  of  retaining  a  familiar  term,  it 
seems  advisable  to  abandon  it  as  not  only  defective,  but  misleading. 
An  accurate  and  scientific  nomenclature  can  arise  only  in  the 
light  of  precise  and  adequate  knowledge.  In  attempting  to  frame 
such  upon  a  pathological  basis,  it  is  before  all  else  essential  that 
the  terms  adopted  should  possess  these  requisites  of  precision 
and  adequacy.  Such  words  as  'sepsis,'  'septic,'  'infection,'  etc., 
must,  if  employed  at  all,  be  employed  in  strict  conformity  with 
established  pathological  usage. 

The  main  current  of  recent  authoritative  opinion  favours  the 
use  of  the  terms  'puerperal  septicaemia'  or  'septic  infection.' 
To  both  there  is  the  sufficient  objection  that,  even  on  the  showing 
of  those  who  use  them,  they  fail,  if  correctly  applied,  to  cover  the 
ground.  Putrid  intoxication,  perhaps  the  most  common  form 
of  puerperal  fever,  cannot  properly  be  ranked  either  as  a  septi- 
caemia or  as  a  septic  infection.  The  distinction  between  the  two 
conditions  is  equally  marked,  whether  considered  from  a  clinical 
or  a  pathological  standpoint. 

Both  conditions  owe  their  origin  to  the  activities  of  micro- 
organisms, and  both  are  toxaemias  ;  but  in  the  case  of  the  first — 
putrid  intoxication  or  sapraemia,  as  it  was  called  by  Matthews 
Duncan — the  micro-organisms  are  saprophytes,  which  do  not  and 
cannot  invade  living  tissues,  but  are  able,  by  their  decomposing 
action  on  dead  tissues  along  the  track  of  the  genital  canal,  to 
manufacture  poisons  locally,  the  systemic  absorption  of  which  is 
the  main  cause  of  symptoms  ;  while  in  that  of  the  second — septic 
infection — the  micro-organisms  are  parasites,  which  invade  living 
tissues,  multiply  within  them,  and  within  them  manufacture  by 
their  metabolism  those  toxins  the  various  effects  of  which  are 
seen  in  the  gravest  of  all  puerperal  diseases.* 

In  both  conditions,  therefore,  there  are  two  features  in  common, 
a  bacterial  origin  and  a  resulting  toxaemia,  and  so  the  term 
1  puerperal  toxaemias '  might  be  correctly  adopted  as  sufficiently 
inclusive.  It  fails,  however,  to  indicate  with  precision  those  cases 
in  which  the  pathological  changes  are  almost  entirely  local,  such 
as  cases  of  puerperal  ulcer  or  local  abscess.  In  these,  indeed, 
a  toxaemia  is  present,  but  it  would  be  pedantic  to  assign  that 
term  as  a  description,  since  its  importance  is  but  slight  in  com- 
parison with  the  local  lesions.  Again,  the  term  '  toxaemia '  is 
insufficient  as  a  description  of  those  infections  where  not  merely 
the  bacterial  toxins,  but  the  bacteria  themselves,  circulate  in  the 
blood-stream. 

We   have    decided,   then,   to   adopt   the   title    '  The    Surgical 

*  The  foregoing  paragraphs  are  from  the  hand  of  the  late  Dr.  W.  C.  Neville, 
to  whom  this  chapter  had  been  first  entrusted.  His  early  death  has  prevented 
the  completion  of  a  task  for  which  he  was  singularly  fitted  by  his  large 
clinical  experience  and  his  sound  pathological  knowledge. 


904  -   PATHOLOGY  OF  THE  PUERPERIUM 

Fevers  of  Childbed  '  as  most  simple,  most  accurate,  and  least 
open  to  objection.  It  is  true  the  term  '  fever'  indicates  a  symptom 
rather  than  a  pathological  condition,  but  it  is  a  symptom  which 
is  common  to  all  these  cases,  and  which  is  usually  the  first  to 
attract  attention.  The  limitation  expressed  by  the  term  'surgical' 
is  of  value,  as  it  excludes  infections  of  the  exanthemata,  such  as 
scarlatina,  occurring  in  the  puerperium  ;  and,  further,  it  serves  to 
emphasize  the  fact  that  the  fevers  of  the  puerperium  are  in  no 
wise  specifically  distinct  from  those  originating  from  surgical 
causes  at  other  periods  of  life. 

Aetiology. — So  far,  we  have  assumed  that  the  fevers  of  which 
we  treat  are  bacterial  in  origin.  This  assumption  at  the  present 
day  is  amply  justified  by  proof,  but  we  must  remember  that,  at 
no  distant  period,  very  different  views  were  held  as  to  their 
aetiology. 

Up  to  the  beginning  of  the  eighteenth  century,  the  doctrine 
which  was  most  generally  held  was  that  puerperal  fever  was  a 
result  of  the  suppression  or  retention  of  the  lochia.  To  this  belief 
Hippocrates,  Galen,  Avicenna,  Albucasis,  Pare,  Petit,  Willis, 
Sydenham,  Boerhaave,  and  many  others,  subscribed,  some  regard- 
ing suppression  of  the  lochia  as  the  only,  others  as  the  principal, 
cause  of  the  disease.  In  the  eighteenth  century,  Ludwig,  Smellie, 
and  Home,  among  others,  expressed  similar  opinions.  This 
traditional  belief,  which  held  sway  for  so  long,  is  hard  to  explain, 
for  disappearance  of  the  lochia  is,  as  we  shall  see,  by  no  means 
a  common  feature  of  the  disease.  It  is  true  that  in  very  acute 
cases  the  lochia  disappear,  but,  before  this  occurs,  the  fever  has 
already  declared  itself;  while,  on  the  other  hand,  many  cases  of 
puerperal  infection  are  accompanied  by  an  increase  in  the  quantity 
of  the  lochia. 

Side  by  side,  however,  with  the  doctrine  of  suppression  of  the 
lochia,  there  grew  up,  from  the  middle  of  the  seventeenth  century 
onwards,  a  belief  in  the  efficiency  of  '  milky  metastasis  '  as  a  cause 
of  puerperal  fever,  and  this  belief  is  still  held  to  some  extent  by 
the  general  public,  as  the  persistence  of  the  terms  '  milk  fever  * 
and  'milk  leg'  testifies.  Writing  in  1870,  Hervieux*  asks: — 
'  How  many  women,  even  of  the  better  class,  do  we  not  see  Who 
refer  puerperal  accidents,  or  their  consequences,  to  the  milk  gone 
wrong  '  (lait  repandu)  ? 

During  the  eighteenth  century,  most  writers  on  obstetrical 
subjects  mention  milky  metastasis  as,  at  any  rate,  one  of  the 
causes  of  puerperal  fever,  while  many  of  them  regard  it  as  the 
principal  or  sole  cause.  The  doctrine  generally  put  forward  was 
that  an  excess  of  milk  was  formed,  according  to  some  in  the 
blood,  to  others  in  the  breasts,  and  that  this  milk,  instead  of 
being  discharged  by  the  breasts,  found  its  way  to  the  generative 
organs,  or  other  abnormal  situations,  giving  rise  to  a  pathological 
condition.  Thus,  in  a  memoir  on  the  epidemic  of  puerperal  fever 
*  '  Traite  des  Maladies  Puerperales,'  p.  6. 


7ETI0L0GY  OF  THE  SURGICAL  FEVERS  905 

which  occurred  in  Paris  in  1746,  De  Jussieu  and  his  colleagues 
mention*  that  in  post  mortem  examinations  they  discovered  a 
'  milky  serosity  '  in  the  cavity  of  the  pelvis,  and  '  clotted  milk  '  on 
the  surface  of  the  intestines.  In  1769,  Boute  similarly  points  to 
the  occurrence  of  'milky  or  puriform  lochia'  in  certain  cases. f 
A  few  years  later,  Leroy  identifies  abscesses  with  collections  of 
milk,!  and  other  writers  fall  into  the  same  error.  Towards  the 
end  of  the  century,  however,  this  view  began  to  be  questioned, 
and  finally  it  received  its  death-blow  from  Bichat,  who  in  1801 
explained  the  lesions  observed  in  the  peritoneum  as  due  to  in- 
flammation, and  demonstrated  their  occurrence  in  men  and  in 
non-lactating  women. §  Curiously  enough,  Dease  of  Dublin, 
writing  twenty  years  earlier,  had  mentioned  finding  in  the 
abdominal  cavities  of  males,  dead  after  operation  for  the  stone, 
similar  appearances  to  those  observed  in  puerperal  fever,  but  he 
failed  to  realise  the  full  significance  of  his  observation.; 

While  the  milk  doctrine  was  the  more  fashionable  one  on  the 
Continent,  an  alternative  belief,  and  one  better  grounded,  was 
obtaining  more  and  more  support  in  England.  This  was  the 
theory  of  a  specific  puerperal  fever.  This  theory  was  not  in  all 
cases  independent  of  the  two  we  have  previously  mentioned,  for 
while  some  regarded  the  fever  as  due  to  putrid  absorption  of 
retained  lochia,  others  brought  it  into  relation  to  milky  metastasis. 
Some  writers,  such  as  Willis,*!  definitely  distinguished  putrid  fever 
from  milk  fever,  and  he  mentioned  as  a  third  class,  putrid  fever 
complicated  by  pleurisy,  small-pox,  and  other  secondary  condi- 
tions. The  many  epidemics  of  puerperal  fever  which  visited 
great  cities  and  maternities  during  the  eighteenth  century,  such 
as  those  at  Paris  in  1746,  at  Rotterdam  in  1766,  at  London 
in  1770,  at  Vienna  in  1771,  and  at  Edinburgh  in  1775,  naturally 
strengthened  the  belief  in  the  specific  nature  of  the  disease,  but 
it  was  not  until  long  afterwards  that  epidemics  were  explained 
on  the  principle  of  contagion. 

Nevertheless,  during  this  period,  from  time  to  time  writers 
put  forward  accounts  of  the  incidence  of  the  disease  which  could 
not  be  explained  on  any  other  principle  than  that  of  infection. 
Thus,  in  1795,  Gordon,  noticing  the  morbidity  attending  his  own 
practice,  confesses  : — '  It  is  a  disagreeable  declaration  for  me  to 
make,  that  I  myself  was  the  means  of  carrying  the  infection  to  a 
great  number.' 

From  this  time  on  to  the  middle  of  the  nineteenth  century,  the 
doctrine  of  an  infective  puerperal  fever  as  a  clinical  entity 
gradually  gained    ground.     Nevertheless,   many  observers  both 

*  A.   de  Jussieu,  Col  de  Villars,  et  Fontaine,   '  Memoires  de   l'Academie 
royale  des  Sciences. '     Paris,  1746. 
■j-  Journal  de  Medecine,  vol.  xxx.,  pp.  27  and  112.     Paris,  1769. 
X  '  Melange  de  Medecine  et  de  Physique,'  p.  198. 
§  '  Anatomie  Generale,'  vol.  iii. 

II    '  Observations  in  Midwifery,' p.  113.     Dublin,  1783. 
H  '  Opera  Medica  et  Physica,'  Bk.  xvi.,  1676. 


906  PATHOLOGY  OF  THE  PUERPERIUM 

then  and  in  the  previous  century  emphasised  the  local  nature 
of  some  cases  of  puerperal  fever,  and  while  some  considered 
inflammation  of  the  uterus  the  essential  lesion,  others  regarded 
inflammation  of  the  peritoneum  as  more  important.  Towards  the 
end  of  the  eighteenth  century,  too,  it  was  maintained  by  many, 
of  whom  Kirkland  is  perhaps  the  most  notable,  that  under  the 
term  '  puerperal  fever  '  many  distinct  conditions  or  diseases  are 
to  be  included. 

During  the  first  half  of  the  nineteenth  century,  there  does  not 
seem  to  have  been  any  very  marked  effort  made  to  solve  the 
problem  of  the  childbed  fevers  in  a  scientific  manner,  and  many 
of  the  most  skilful  obstetricians  refused  to  make  any  scientific 
hypothesis  as  to  the  causation  of  the  disease,  preferring  to  regard 
it,  as  Meigs  put  it,  '  as  due  to  the  workings  of  Providence.' 
During  this  period,  too,  the  hypothesis  of  miasmic  origin  was 
first  brought  forward,  a  hypothesis  whose  later  developments 
may  be  traced  in  the  more  modern  doctrine  of  air  infection. 

A  definite  step  in  advance  was  made,  however,  in  1843,  when 
Oliver  Wendell  Holmes  published,  in  an  essay  entitled  '  The 
Contagiousness  of  Puerperal  Fever,'  his  reasons  for  believing  that 
puerperal  fever  was  carried  to  the  patient  by  the  accoucheur  or 
the  nurse,  and  that,  therefore,  it  was  preventable.  His  teaching 
met  with  the  most  bitter  opposition,  and  called  forth  from  Meigs, 
one  of  the  leading  obstetricians  of  the  day,  the  remark  we  have 
quoted  above. 

While  Holmes  was  persisting  in  the  promulgation  of  his  views 
in  America,  Semmelweiss,*  assistant  in  the  maternity  at  Vienna, 
noticed  that  the  mortality  among  women  attended  by  students 
during  confinement  was  three  times  greater  than  that  in  the 
wards  where  only  midwives  were  in  attendance.  While  searching 
diligently  for  the  cause  of  this  striking  difference,  one  of  his 
colleagues  died  of  pyaemia,  the  result  of  a  dissecting-wound.  By 
a  flash  of  genius,  the  matter  became  clear  to  Semmelweiss,  and 
he  was  soon  able  to  announce  that  puerperal  fever  was  an 
infection  carried  to  the  uterus  in  the  form  of  a  cadaveric  poison 
on  the  hands  of  the  students,  who  came  fresh  from  the  dissecting- 
room  to  the  lying-in  wards.  By  the  simple  device  of  insisting  on 
the  students  cleansing  their  hands  in  chloride  of  lime,  he  was 
able  to  reduce  the  mortality  in  the  lying-in  wards  to  less  than 
one  per  cent. 

There  is  no  need  to  trace  further  the  history  of  the  study  of 
puerperal  infection.  The  only  correction  needed  in  Semmelweiss' 
pronouncement,  to  bring  it  into  line  with  modern  views,  is  to 
substitute  '  bacillary  virus  '  for  '  cadaveric  poison.'  This  develop- 
ment has  been  made  by  the  researches  of  Pasteur  and  Lister, 
and  the  identity  of  puerperal  fever  with  one  or  other  of  the  forms 
of  surgical  infection  is  now  undoubted.    The  conditions  necessary 

*  Wiener  Zeitschrift,  December,  1857  ;  '  Die  iEtiologie,  der  Begriff,  und  die 
Prophylaxis  des  Kindbettfiebers. '     Vienna,  1861, 


NATURE  OF  THE  INVADING  ORGANISMS  907 

to  establish  a  causal  relation  between  an  organism  and  a  disease 
— the  constant  association  of  the  organism  with  the  disease ;  its 
separation  and  growth  in  pure  culture  outside  the  body  ;  and  the 
production,  by  inoculation  of  animals  with  the  organism,  of  lesions 
similar  to  those  characteristic  of  the  disease — have  been  fulfilled 
many  times  in  the  case  of  the  puerperal  infections. 

Parasitic  Organisms. — The  bacterial  origin  of  the  fevers  of 
childbed  being  established,  the  next  point  is  to  study  the  nature 
of  the  invading  organisms.  They  are  similar  to  those  found  in 
other  forms  of  surgical  infection,  and,  if  for  the  present  we 
exclude  the  putrefactive  organisms  which  are  the  causes  of 
sapraemic  intoxication,  we  shall  find  that  the  organisms  most 
commonly  present  in  childbed  fevers  are  streptococcus  pyogenes, 
staphylococcus  pyogenes  and  bacillus  coli,  and  that  others  occasionally 
met  with  are  gonococcus,  bacillus  diphtheria,  bacillus  tetani,  pneumo- 
coccus,  and  possibly  bacillus  aerogenes  capsulatus. 

Streptococcus  Pyogenes. — So  long  ago  as  1863,  the  occurrence  of 
the  streptococcus  in  cases  of  fever  in  childbed  had  been  noted 
by  Mayrhofer,  and  shortly  afterwards  by  others,  including  Coze, 
who  in  1869  found  it  in  the  blood  in  a  fatal  case.  It  remained, 
however,  for  Pasteur  in  1879  to  prove  that  this  organism  was 
the  causal  factor  in  several  cases  investigated  by  him.  His 
researches  have  been  amply  borne  out  by  many  observers  in 
the  years  that  have  since  elapsed,  and  in  the  severer  forms  of 
infection  the  streptococcus  pyogenes  is  nearly  always  found,  either 
alone  or  in  association  with  other  organisms. 

The  streptococcus  is  widely  distributed  in  nature,  and  has  been 
found  in  floor-dust,  in  river-water,  on  the  skin,  and  in  the  mouths 
of  healthy  individuals.  Under  these  conditions,  it  possesses  but 
a  low  degree  of  virulence.  Its  virulence  is,  indeed,  very  variable, 
and,  experimentally,  it  can  be  increased  to  a  high  point  by  succes- 
sive inoculation  from  animal  to  animal,  or  by  alternation  between 
inoculation  of  animals  and  culture  in  vitro.  The  same  race  of  the 
organism  can  thus  be  made  to  produce  effects  varying  in  degree 
from  a  mere  passing  erythema  to  a  rapidly  fatal  septicaemia. 

The  streptococcus  is,  therefore,  found  associated  with  conditions 
differing  entirely  in  their  clinical  manifestations.  It  may  cause 
local  suppuration  such  as  a  boil  or  a  carbuncle,  or  an  extensive 
phlegmon.  It  is  the  cause  of  the  wide-spreading  dermal  inflamma- 
tion termed  erysipelas,  and  of  the  inflammations  of  the  blood  and 
lymph  channels  known  as  phlebitis  and  lymphangitis.  It  is  more- 
over frequently  found  in  apparent  symbiosis  with  other  organisms, 
and,  in  such  cases,  the  process  has  usually  a  greater  virulence 
than  if  a  single  organism  alone  were  concerned.  Thus,  when  a 
diphtheritic  or  a  tubercular  infection  receives  a  secondary  im- 
plantation of  streptococcus,  it  usually  proceeds  more  rapidly,  and 
greater  injury  to  the  tissues,  as  well  as  more  severe  toxaemia, 
results. 

The  infection  of  puerperal  women  with  streptococcus  derived 


908  PATHOLOGY  OF  THE  PUERPERIUM 

from  streptococcal  lesions  in  other  patients,  has  been  often  noted, 
and,  in  particular,  the  connection  with  erysipelas  is  well  known. 
This  is  all  the  more  interesting  as  there  was  for  long  a  difference 
of  opinion  among  bacteriologists  on  the  identity  of  the  streptococcus 
pyogenes  with  the  streptococcus  erysipelatis  of  Fehleisen.  This  point 
is  now  settled,  and  the  two  are  believed  to  be  identical. 

Staphylococcus  Pyogenes. — Shortly  after  Pasteur  made  known  the 
connection  of  the  streptococcus  with  puerperal  infection,  other 
observers  drew  attention  to  the  occurrence  of  a  staphylococcus 
which  has  since  been  identified  with  the  staphylococcus  pyogenes 
aureus.  It  has  been  found  in  the  lochia,  in  the  pus  of  pelvic 
abscesses,  in  peritoneal  inflammations,  in  metastatic  abscesses, 
and  in  secondary  infections  of  the  serous  surfaces,  such  as  the 
pleura  and  pericardium. 

The  staphylococcus  pyogenes,  of  which  there  are  three  varieties, 
aureus,  albus,  and  citreus,  the  first  being  that  most  concerned  in 
puerperal  infections,  has  an  even  wider  distribution  in  nature  than 
the  streptococcus,  and  has,  speaking  generally,  very  similar  pro- 
perties. It  is  found  practically  everywhere — ^on  the  skin,  on  the 
clothes,  in  the  dust  of  the  floor  and  of  the  street,  and  it  is  con- 
stantly present  in  the  mouth  and  upper  air-passages.  It  must 
always  be  remembered,  however,  that  pathogenic  organisms  tend 
to  lose  their  virulence  when  living  in  a  non-pathogenic  condition, 
and  there  is,  therefore,  much  less  danger  of  infecting  a  wound  by 
the  introduction  of  a  drop  of  healthy  saliva  than  of  a  drop  of  pus, 
even  if  the  number  of  pathogenic  organisms  is  the  same  in  each. 
Pathologically,  the  staphylococcus  is  most  commonly  found  in 
association  with  circumscribed  abscesses,  particularly  those  in 
connection  with  the  skin.  It  may  give  rise  to  metastatic 
abscesses,  but  it  rarely  causes  a  profound  toxaemia,  and  it  has 
no  power  to  produce  diffuse  penetrating  inflammations  such  as 
erysipelas.  When  it  is  present  in  such  cases,  it  is  usually  in 
association  with  the  streptococcus. 

It  has  been  often  stated  that  the  pathological  results  of  a 
puerperal  infection  with  staphylococcus  are  less  severe  than 
those  due  to  streptococcus,  but  it  is  probable  that  this  is  a 
hasty  generalisation,  as  several  cases  of  very  severe  staphylo- 
coccal infection  are  on  record. 

Bacillus  Coli  Communis. — The  bacillus  coli  communis  is  of  more 
frequent  occurrence  than  the  staphylococcus.  Whitridge 
Williams,*  in  an  examination  of  150  cases  where  the  tempera- 
ture rose  to  1010  F.  during  the  first  ten  days  of  the  puerperium, 
found  the  colon  bacillus  present  in  the  uterine  lochia  in  twenty 
cases,  in  eleven  of  which  it  was  the  only  organism  discovered. 
In  fifty-four  cases  of  puerperal  fever  examined  by  Foulerton  and 
Bonney,f  the  colon  bacillus  was  found  in  the  uterine  contents 
in  seventeen. 

The  frequency  of  infection  by  the  colon  bacillus  is  easily  ex- 
*   '  Text-book  of  Obstetrics,'  1901,  p.  762.  j  Practitioner,  March,  1905. 


NATURE  OF  THE  INVADING  ORGANISMS  909 

plained  by  the  habitual  presence  of  that  organism  in  the  intestines 
under  normal  circumstances.  The  bacillus  is,  moreover,  dis- 
charged in  enormous  quantities  in  the  fasces.  It  has  the  property 
in  certain  media  of  producing  gas,  and  also  of  forming  indol,  and 
both  these  actions  are  normally  exercised  in  the  intestine.  It  is 
probable  that  the  colon  bacillus,  so  long  as  it  remains  in  the 
intestine,  is  harmless,  though  some  observers  have  credited  it 
with  the  production  of  certain  of  the  summer  diarrhoeas,  and 
during  typhoid  fever,  it  usually  undergoes  changes  which  increase 
its  virulence,  as  shown  by  inoculation.  When,  however,  the 
bacillus  finds  its  way  into  situations  other  than  the  intestine,  it  is 
distinctly  pathogenic.  In  infections  of  the  peritoneum,  which 
have  spread  through  the  intestinal  wall,  whether  by  a  perforation 
or  otherwise,  the  colon  bacillus  is  the  infecting  organism.  It  is 
especially  noted  in  abscesses  and  inflammations  originating  in 
relation  to  the  appendix,  and  occasionally,  but  more  rarely,  it  is 
responsible  for  secondary  inflammations  of  the  pericardium  and 
pleura.  From  its  constant  occurrence  in  the  faeces,  it  is  obvious 
that  any  soiling  of  the  skin  round  the  anus  will  deposit  it  in  that 
neighbourhood,  and  the  fact  that  it  is  the  most  common  organism 
met  with  in  acute  inflammations  of  the  urinary  passages,  can  be 
explained  by  its  introduction  into  the  bladder  on  catheters  which 
have  been  infected  by  contact  with  these  parts.  The  motile  power 
possessed  by  the  bacillus  enables  it  to  extend  its  area  of  infection. 
The  term  '  bacillus  coli '  should  not  be  regarded  as  the  name  of 
a  definite  species.  It  is  rather  the  common  term  applied  to  a 
number  of  types,  in  virtue  of  the  possession  of  certain  properties 
in  common,  although  the  different  races  concerned  may  differ  in 
many  points  of  detail.  Closely  allied  to  the  bacteria  of  the  colon 
group,  if  not  actually  to  be  included  in  it,  are  such  organisms  as 
the  typhoid  bacillus,  and  the  various  species  which  have  been 
decribed  as  '  paratyphoid  '  and  '  paracolon.'  On  account  of  this 
relationship,  it  is  well  to  draw  attention  here  to  certain  puerperal 
infections  which  have  been  reported  by  various  observers  as  due 
to  the  typhoid  bacillus.  One  apparently  authentic  case  was 
observed  by  Whitridge  Williams  and  Dobbin,*  where  the 
typhoid  bacillus,  along  with  other  organisms,  was  separated  from 
the  lochia,  and  where  the  blood  reacted  to  the  agglutination  test. 
All  the  usual  symptoms  of  typhoid  fever  were  absent.  The  patient 
had  been  confined  on  the  bed  where  her  husband  had  died  shortly 
before  of  typhoid  fever,  and  the  reporters  believed  that  the  infec- 
tion had  been  introduced  to  the  genital  passages  on  the  hand  of 
the  midwife.  In  most,  if  not  all,  of  the  other  reported  cases, 
however,  the  presence  of  typhoid  bacilli  in  the  lochia  was  probably 
secondary  to  infection  of  the  intestine,  so  that  such  cases  are  to  be 
regarded  rather  as  typhoid  fever  occurring  during  the  puerperium 
than  as  a  true  puerperal  infection  with  the  typhoid  bacillus.  Even 
in  Williams'  and  Dobbin's  case  this  explanation  is  not  excluded,  as 
*  American  Journal  of  Obstetrics,  August,  1898. 


910  PATHOLOGY  OF  THE  PUERPERIUM 

the  woman  recovered,  and  it  was  therefore,  impossible  to  discover 
the  condition  of  the  intestines;  while  in  a  case  reported  by 
Blumer,*  in  which  the  clinical  symptoms  were  very  similar,  an 
autopsy  revealed  the  presence  of  typical  typhoid  lesions  in  the 
intestine. 

Gonococcus. — Out  of  179  cases  of  puerperal  infection  recorded 
by  Kronig,  the  gonococcus  was  separated  in  fifty  ;  while  out  of 
150  cases  recorded  by  Williams,  where  the  temperature  reached 
1010  F.,  the  gonococcus  was  present  in  eight.  Recent  writers,  how- 
ever,! are  inclined  to  doubt  the  accuracy  of  these  observations,  and 
are  of  opinion  that  the  organism  separated  in  most  cases,  though 
resembling  the  gonococcus  in  certain  particulars,  could  with  care 
be  distinguished  from  it.  Whether  it  is  the  gonococcus  or  not, 
a  diplococcus  resembling  it  in  shape  is  found  very  frequently 
in  the  uterus  in  infections  which  are  unaccompanied  by  severe 
septicaemia  or  extensive  suppuration. 

Bacillus  Diphtheria. — As  is  well  known,  true  diphtheria,  due  to 
the  Klebs-Loffler  bacillus,  occasionally  occurs  on  the  vulva,  and  in 
some  instances  a  true  diphtheritic  membrane  may  form  on  the 
vulva  and  in  the  vagina  during  the  puerperium.  This  is  quite  a 
different  pathological  condition  from  so-called  '  diphtheritic  endo- 
metritis,' where  the  causal  organism  is  usually  the  streptococcus. 
The  writer  has  not  met  with  any  reports  of  true  diphtheria  of 
the  uterus. 

Bacillus  Tetani. — A  large  number  of  cases  of  tetanus  occurring 
during  childbed  have  been  recorded  by  Chantemesse,  Rubeska 
and  others,  and  the  tetanus  bacillus  has  been  found  in  the  dis- 
charges. In  most  cases  where  this  infection  occurs,  the  con- 
finement has  taken  place  amid  filthy  surroundings,  and  without 
proper  antiseptic  precautions.  This  form  of  infection  is  said  to 
occur  more  frequently  after  abortion  than  after  labour  at  full  term. 

Pneumococcus. — In  recent  papers,  Foulerton  and  Bonneyf  have 
drawn  attention  to  the  frequency  with  which  they  have  found 
this  organism  in  the  uterus  in  cases  of  puerperal  fever.  A  few 
other  cases  are  on  record. 

Bacillus  Aero  genes  Capsulatus. — The  gas  bacillus,  though  de- 
scribed as  parasitic,  is  probably  only  present  as  a  saprophyte, 
in  cases  in  which  infection  by  some  other  organism  has  occurred. 
It  is  said  to  be  responsible  for  the  occurrence  of  the  condition 
known  as  Hympania  uteri,'  and  it  has  been  pointed  out  by  Dobbin 
and  others  that  the  diagnosis  of  '  air  embolism  '  has  probably 
been  made  in  some  cases  where  the  supposed  air  was  in  reality 
gas  formed  by  this  organism.  The  presence  of  bubbles  in  the 
lochia  may  be  due  to  this  organism,  to  the  colon  bacillus,  or  to 
various  sapraemic  germs. 

The  organisms  described  in  the  foregoing  paragraphs  are  re- 

*  American  Journal  of  Obstetrics,  1899,  p.  42. 

f  Transactions  of  the  Obstetrical  Society  of  London,  1905 ;  and  Practitioner, 
March,  1905. 


NATURE  OF  THE  INVADING  ORGANISMS  911 

sponsible  for  the  great  majority  of  cases  of  puerperal  infection. 
It  cannot  be  claimed,  however,  that  the  list  is  exhaustive.  In 
many  cases  unidentified  bacilli,  many  of  them  anaerobic,  have 
been  seen,  though  usually  they  are  in  association  with  one  or 
other  of  those  we  have  described.  Sometimes,  however,  they 
occur  alone. 

Putrefactive  Organisms. — In  the  introductory  paragraphs  of  this 
chapter,  a  distinction  was  made  between  septic  and  sapraemic 
conditions.  In  the  preceding  paragraphs,  we  have  described  the 
parasites  responsible  for  the  former  class,  and  it  now  remains  to 
speak  of  the  saprophytes  which  cause  the  latter. 

Putrefactive  organisms  differ  in  one  important  respect  from  the 
organisms  that  cause  septicaemia,  in  that  they  are  incapable  of 
multiplying  in  living  tissues.  That  is  to  say,  they  are  not  true 
parasites,  and  consequently  we  cannot  speak  of  infection  by 
saprophytes,  but  only  of  intoxication.  The  particular  organisms 
concerned  are  among  those  that  are  active  in  ordinary  putre- 
factive processes  outside  the  body.  They  are  everywhere  present 
in  nature,  though  their  activity  is  greatly  hindered  by  extreme 
cold.  In  warm  weather,  on  the  other  hand,  putrefactive  pro- 
cesses become  much  more  rapid.  The  varieties  of  such  organisms 
are  very  many,  and,  up  to  the  present,  there  has  been  but  little 
attempt  to  classify  them.  Those  usually  found  in  sapraemia  are 
anaerobic,  and  many  of  them  produce  gas  of  unpleasant  odour. 
Bumm,  Doderlein,  Kronig,  and  others,  have  separated  various 
saprophytic  organisms  from  the  lochia,  but  it  is  not  necessary, 
nor  indeed  possible,  to  make  any  definite  statements  as  to  those 
most  commonly  concerned. 

Although  we  have  thus  carefully  distinguished  sapraemia  from 
the  parasitic  infections,  there  is  considerable  doubt  whether  it 
ever  exists  quite  alone.  It  is  quite  possible  that  a  retained 
piece  of  placenta  or  of  membranes  may  undergo  putrefactive 
decomposition  in  the  uterus,  without  any  infection  of  the  uterine 
walls  taking  place,  but,  in  the  majority  of  cases,  there  is  probably 
very  little  absorption  of  toxins,  unless  the  uterus  is  attacked  at 
the  same  time  by  a  parasitic  infection.  Nevertheless,  although 
theoretically  a  pure  sapraemia  may  be  rare,  clinically  the  dis- 
tinction between  sapraemia  and  septicaemia  is  quite  clear ;  in 
other  words,  in  many  cases  all  the  symptoms  of  the  patient 
point  to  the  absorption  of  poisons  and  to  local  putrefaction, 
and  not  to  a  bacterial  invasion  of  the  tissues.  Such  cases  are 
classed  as  sapraemia. 

Predisposing  Causes.  —  In  those  diseases  which  are  due  to 
bacterial  invasion,  there  is  always  a  danger  of  overlooking  the 
conditions  which  favour  the  entrance  into  the  system,  or  the 
growth,  of  the  invading  organism.  These  conditions  are,  how- 
ever, of  the  utmost  importance,  as  without  them  infection  will 
not  occur.  It  may  be  said  that  anything  which  tends  to  lower 
the  vitality  of  the  subject  thereby  decreases   the  resistance    to 


912  PATHOLOGY  OF  THE  PUERPERIUM 

bacterial  invasion.  Thus,  a  difficult  or  prolonged  labour,  or  a- 
labour  involving  operative  interference  and  severe  haemorrhage, 
is  more  liable  to  be  followed  by  infection  than  is  a  normal 
labour.  If  to  these  conditions  are  added  a  general  condition 
of  debility,  as  from  overwork,  bad  hygienic  surroundings,  or, 
wasting  disease,  the  liability  is  increased.  It  is  probable  that, 
the  custom  still  observed  by  some  physicians  of  keeping 
puerperal  patients  on  unnecessarily  low  diet  is  responsible  -for. 
occasionally  bringing  about  a  susceptibility  to  infection. 

From  very  early  times,  it  has  been  shown  that,  in  cases  where 
the  confinement  is  accompanied  by  mental  distress,  puerperal 
infection  is  more  likely  to  follow.  In  some  cases,  the  distress 
may  be  merely  the  result  of  a  nervous  temperament,  which  makes 
the  patient  look  forward  with  anxiety  to  her  first  confinement, 
while  in  others,  it  may  be  due  to  the  disgrace  attending  illegiti- 
mate motherhood,  accompanied  by  the  distress  of  possible  deser- 
tion. There  is  every  reason  to  believe  that  such  mental  conditions 
are  important  predisposing  causes  of  infection. 

Slight  or  severe  abrasions  or  lacerations,  and,  in  fact,  all 
breaches  of  continuity  in  the  genital  mucous  membrane,  offer 
channels  for  infection.  Moreover,  prolonged  labour,  by  giving 
more  opportunity  for  vaginal  examinations,  and  thereby  increasing 
the  chance  of  infectious  material  being  deposited  in  the  genital 
passages,  increases  the  danger.  For  these  reasons,  it  is  probable 
that  primiparae  are  more  prone  to  infection  than  are  multiparas, 
as  in  them  genital  lacerations  and  prolonged  labour  are  more 
frequent. 

There  is  little  doubt  that  the  adoption  of  the  recumbent 
position  during  the  early  days  of  the  puerperiurn  increases  the 
chance  of  infection  by  preventing  free  drainage  of  the  lochia  from 
the  vagina.  Kinkead  believes*  that  the  comparative  freedom 
from  puerperal  sepsis  of  country  women  in  the  West  of  Ireland, 
in  spite  of  insanitary  surroundings  and  attendance  by  septic 
midwives,  is  due  to  their  custom  of  sitting  up  m  bed  almost 
immediately,  and  walking  about  in  two  or  three  days  after 
delivery.  As  long  ago  as  1785,  White  insisted  on  his  patients 
sitting  up  a  few  hours  after  delivery,  and  getting  out  of  bed  on 
the  second  day,  and  he  believed  that  by  this  means  he  avoided 
the  occurrence  of  puerperal  fever,  t 

A  necessary  condition  for  saprophytic  intoxication  is  the 
presence  of  dead  material  in  the  uterus  or  vagina.  Such  material 
may  be  provided  by  the  retention  of  lochia  in  the  genital  passages, 
or  by  the  retention  of  a  portion  of  placenta  or  membrane  in  the 
uterus. 

A  very  common  predisposing  cause,  and  one  to  which  all  par- 
turient women  are  liable,  is  constipation.     The  auto-intoxication 

*  American  Journal  of  Obstetrics,  vol.  xviii.,  p.  8. 

•j-  'Treatise  on  the  Management  of  Pregnant  and  Lying-in  Women,'  third 
edition,  1785,  p.  ir8  et  seq. 


SAPRMMIA  9,$ 

to  which  this  condition  gives  rise  is  probably  of  more  importance 
as  a  predisposing  factor  in  the  causation  of  many  of  the  infective 
diseases  than  any  one  other  condition  that  can  be  named. 

We  have  already*  discussed  the  manner  in  which  septic  and 
sapraemic  organisms  gain  entrance  to  the  genital  tract,  and  so  we 
need  not  here  refer  to  it. 


SAPILEMIA 

By  the  term  '  sapraemia '  is  meant  the  condition  of  intoxication 
resulting  from  the  absorption  of  the  poisons  produced  by  putre- 
factive decomposition.  For  the  most  part  these  poisons  are  of 
the  nature  of  ptomaines,  bodies  which  in  their  chemical  characters 
closely  resemble  the  vegetable  alkaloids.  They  are,  however, 
much  less  stable,  and,  consequently,  more  difficult  to  obtain  in 
pure  form.  Extracts  of  some  of  them  have  been  obtained,  and 
their  toxicity  demonstrated  by  their  action  on  animals.  In  the 
body,  their  toxic  effect  is  either  convulsive  or  narcotic,  and  they 
produce  the  constitutional  symptoms  to  be  presently  described. 

Pathological  Anatomy.  —  In  cases  of  retained  lochia,  a  slight 
absorption  of  saprophytic  poisons  may  take  place  without  any 
accompanying  anatomical  lesion  beyond  a  slight  congestion  of  the 
mucous  membrane  of  the  vagina  or  uterus,  due  to  the  irritation  of 
the  tissues  by  the  decomposing  lochia.  The  most  typical  local 
condition,  however,  associated  with  sapraemia  is  an  inflammation 
of  the  uterus  known  as  putrid  endometritis.  The  uterus  is  found 
to  be  large,  soft,  and  flabby  ;  its  inner  surface  is  covered  with  a 
rough,  friable,  and  stinking  slough,  which  easily  tears  away  in 
large  masses,  and  it  is  bathed  in  a  dirty,  frothy,  and  bloody  or 
purulent  fluid.  The  lochia  have  a  similar  character,  and  contain 
necrosed  portions  of  the  uterine  wall  of  varying  size.  They  are 
peculiarly  ill-smelling  (v.  Fig.  383). 

The  microscopical  character  of  the  inflammation  is  also  dis- 
tinctive from  that  of  other  types  of  endometritis.  The  layer  of 
necrosis  is,  as  the  gross  appearance  tells,  much  thicker  than  in 
septic  endometritis.  In  the  living  tissue  underlying  it,  there  is 
a  zone  of  infiltration  where  the  leucocytes  are  densely  crowded 
together.  The  organisms  are  almost  completely  confined  to  the 
necrotic  layer,  and,  though  a  few  bacilli  may  be  seen  in  the  more 
superficial  parts  of  the  layer  of  leucocytes,  none  will  be  found  in 
its  deeper  parts  or  beneath  it  (v.  Figs.  378,  379). 

Although  this  form  of  endometrial  inflammation  is  always 
associated  with  sapraemic  symptoms,  it  cannot  be  said  to  be  due 
in  its  entirety  to  saprophytic  irritation.  In  probably  every  case, 
a  careful  bacteriological  examination  will  show  the  presence  of 
pathogenic  germs  in  addition  to  true  saprophytes.  Moreover, 
the  form  of  endometritis  commonly  due  to  infection  with  the 
*   Vide  Part  II.,  Chap.  I. 

58 


9'4 


PATHOLOGY  OF  THE  PUERPERIUM 


colon  bacillus,  either  alone  or  in  conjunction  with  other  parasitic 
germs,  cannot  be  distinguished  from  that  just  described.  It  is 
probable  that  in  many  cases  of  putrid  endometritis,  irritation  by 
saprophytic  poisons  is  the  first  step  towards  an  infection  by  septic 
organisms,  which  in  their  turn  produce  superficial  necrosis  of 
the  uterine  wall,  and  thereby  supply  further  pabulum  for  the 
saprophytes. 

The  general  pathological   changes   due   to   sapraemia   can  be 
described   in   a   few   sentences.     The   blood   is   dark   in  colour, 


•\-v-Vv 


^  1&..'&ki3»>^u.c  ,^tc. 


Fig.  378. — Puerperal  Endometritis  due   to  Colon  Infection,  showing 
Marked  Development  of  Leucocytic  Wall.     (Williams.) 

coagulates  imperfectly,  and  tends  to  stain  the  vessel  walls.  There 
is,  in  fact,  a  disintegration  of  the  red  corpuscles,  showing  that  on 
them  at  any  rate  the  toxins  exert  some  influence.  Small,  dark 
extravasations  of  blood  occur  in  the  serous  membranes,  skin,  and 
elsewhere,  and  there  may  be  slight  bloody  effusions  into  the  serous 
cavities.  The  spleen,  liver,  and  kidneys  are  swollen  and  dark  in 
colour.  Rigor  mortis  in  fatal  cases  is  badly  marked,  and  decom- 
position is  very  rapid. 

Symptoms. — The  symptoms  of  sapraemia  may  be  divided  into 
two  groups.  In  the  first  group  are  the  local  symptoms  due  to  the 
presence  of  a  centre  of  decomposition  in  the  vagina  or  uterus,  and 


THE  SYMPTOMS  OF  SAPRJEMIA 


915 


in  the   second   group  the  constitutional   symptoms   due    to   the 
absorption  of  ptomaines  from  this  centre. 

The  first  local  symptom  to  appear  is  an  alteration  in  the 
lochia,  which,  instead  of  being  the  sanguineous  or  sero-san- 
guineous  discharge  that  occurs  during  a  normal  puerperium, 
become  of  a  dirty  brown  colour,  are  increased  in  amount,  and  are 
extremely  foetid.     They  may  also   contain    decomposing    shreds 


Fig.  379. — Colon  Bacillus  Endometritis  ;  Leucocytic  Wall  not 
invaded  by  Bacteria,      x  800.     (Williams.) 


of  decidua  and  membranes.  If  the  saprophytic  infection  has 
occurred  during  labour,  these  changes  usually  appear  about  the 
evening  of  the  second  or  the  third  day,  while,  if  the  infection 
occurs  during  the  puerperium,  they  appear  correspondingly  later. 
The  diapers  or  cotton-wool  pads,  on  which  the  putrid  lochia  are 
collected,  often  furnish  very  clear  evidence  of  the  presence  of  de- 
composition. The  normal  lochia  stain  the  diaper  as  does  blood, 
that  is  to  say,  they  cause  a  stain  which  is  red  in  the  centre  and 
which  fades  away  gradually  into  a  colourless  margin,  an  appear- 

58-2 


gi6  PATHOLOGY  OF  THE  PUERPERIUM 

ance  due  to  the  collection  of  the  fibrin  and  blood  corpuscles  in  the 
centre  of  the  stain,  and  the  peripheral  extension  of  the  serum. 
The  stain  of  decomposing  lochia,  on  the  other  hand,  is  quite 
different.  The  centre  is  almost  the  palest  part,  and  the  edges  are 
hard  and  deeply  stained.  This  appearance,  and  the  odour  of 
decomposition  that  comes  from  the  diaper,  are  quite  characteristic. 
The  next  most  important  local  symptom  is  the  cessation  of  in- 
volution, a  cessation  which  apparently  is  due  to  the  effect  of  the 
absorbed  toxins.  The  uterus  remains  for  several  days  at  almost 
the  same  size  as  it  was  on  the  first  day  after  delivery,  and  often 
is  extremely  tender  on  pressure.  In  some  cases,  the  enlarged 
fundus  falls  into  a  position  of  ante-  or  retro-flexion,  and  in  con- 
sequence a  small  pool  of  decomposing  lochia  may  collect  in  it, 
and,  inasmuch  as  this  means  that  the  lochia  are  retained  for  an 
unduly  long  period  in  the  uterus,  the  constitutional  symptoms 
are  usually  aggravated.  To  this  condition,  the  term  lochio-metra  is 
applied.  If  a  putrid  endometritis  occurs,  the  foregoing  symptoms 
are  exaggerated. 

The  constitutional  symptoms  of  saprasmia  appear  from  the 
third  to  the  fifth  day,  and  usually  commence  gradually.  The 
first  symptoms  are  a  slight  elevation  of  the  temperature  to  ioi° 
or  io2°  F.  and  a  corresponding  increase  in  the  rapidity  of  the 
pulse.  The  patient  may  also  experience  a  slight  chill  or  shivering 
fit,  but  this  as  a  rule  is  insufficiently  marked  to  be  termed  a  rigor. 
If  the  uterus  is  washed  out,  and  the  source  of  the  toxins  removed, 
the  symptoms  usually  disappear  at  once  and  completely.  If,  how- 
ever, the  patient  remains  untreated,  the  symptoms  become  more 
marked,  and  the  temperature  may  rise  a  degree  or  so  on  the 
following  evening,  and  the  pulse-rate  also  increase.  The  patient, 
who  up  to  this  time  has  not  complained  of  any  ill  effects,  may  now 
feel  extremely  ill.  If  the  patient  was  still  to  remain  untreated, 
these  symptoms  would  become  steadily  worse,  and  her  condition 
might  become  critical,  particularly  if  septic  organisms  also  had 
made  their  way  into  the  uterus.  In  such  cases,  the  symptoms 
become  identical  with  those  of  local  septic  infection.  As  has 
been  already  pointed  out,  a  purely  saprophytic  infection  is  of  rare 
occurrence,  and,  if  the  symptoms  become  serious,  it  almost 
always  shows  that  a  mixed  infection  has  occurred. 

Diagnosis. — The  diagnosis  of  sapraemic  infection  is  usually  an 
easy  matter,  as  the  changes  in  the  character  of  the  lochia  are 
very  evident.  It  is  not,  however,  always  easy  to  be  sure  that 
there  is  not  a  concomitant  septic  infection,  unless  a  bacteriological 
examination  is  made.  In  cases  of  doubt,  it  is  always  well  to 
make  such  an  examination. 

Treatment.  —  The  principles  of  the  treatment  of  sapraemia, 
shortly  stated,  are  to  remove,  so  far  as  possible,  all  saprophytic 
organisms  and  decomposing  masses  from  the  uterus  and  vagina, 
and  to  destroy,  by  means  of  antiseptics,  those  which  cannot  be 
removed.    The  removal  of  saprophytic  organisms  may  be  brought 


THE  TREATMENT  OF  S APR JEM 7 A  917 

about  by  copious  and  repeated  vaginal  and  uterine  douches,  and 
by  promoting  free  drainage  from  the  uterus.  As  soon  as  any 
symptoms  of  decomposition  appear,  the  patient  should  be  given 
a  brisk  purgative,  as  the  straining  which  the  latter  causes  helps  to 
empty  the  uterus  and  vagina.  If  the  third  day  is  passed,  the 
patient  may  be  partially  raised  in  bed  by  pillows,  and  also 
allowed  to  kneel  in  bed  when  passing  water.  If  this  treat- 
ment does  not  bring  down  the  temperature  within  twelve  or 
twenty-four  hours,  the  vagina  and  uterus  should  be  washed  out 
with  lysol  or  creolin  solution,  using  a  large  Bozemann's  catheter 
or  glass  nozzle.  The  douche  should  be  given  at  a  temperature 
of  98°  to  ioo°  F.,  and  at  least  half  a  gallon  of  fluid  should  be 
passed  into  the  uterus.  This  douche  should  be  repeated  night 
and  morning  until  the  lochia  return  to  their  normal  condition. 

If,  in  spite  of  douching,  the  lochia  still  remain  foul,  the 
uterus  should  be  explored  with  the  finger,  to  ascertain  if  any 
fragments  of  placenta  or  membranes  have  been  left  behind.  If 
such  fragments  are  found,  they  must  be  scraped  away  by  the 
finger,  or  by  means  of  a  Rheinstadter's  blunt  curette.  In  using 
the  latter,  great  care  must  be  taken  not  to  use  too  much  force, 
as,  in  the  softened  condition  of  the  uterine  wall  which  often 
accompanies  saprophytic  infection,  it  requires  but  little  force  to 
pass  the  curette  through  the  wall.  If  the  uterine  wall  is  rough 
and  shaggy  from  portions  of  retained  decidua,  it  may  be  lightly 
curetted  all  over,  but  in  so  doing  one  must  remember  that  it 
is  quite  possible  to  remove  pieces  of  softened  uterine  muscle,  even 
with  a  blunt  curette.  We  have  seen  quite  large  pieces  of  muscle 
removed  in  this  way,  under  the  idea  that  the  curette  was  only 
removing  retained  placental  fragments.  If  the  lochia  are  retained 
in  the  uterus,  it  is  well  after  douching  to  plug  the  cavity  tightly 
with  iodoform  gauze,  as  this  will  promote  drainage,  and  at  the 
same  time  the  iodoform  will  exert  an  antiseptic  effect.  A  similar 
procedure  may  be  adopted  after  curettage,  in  order  to  destroy 
those  micro-organisms  which  have  not  been  removed  by  the 
curette  or  by  the  douche.  In  such  cases,  the  plug  should  be 
removed  at  the  end  of  twelve  hours,  and,  if  necessary,  a  fresh 
one  inserted.  The  prolonged  action  of  iodoform  has  a  powerful 
germicidal  effect,  and,  when  the  drug  is  introduced  into  the 
uterus  in  small  quantities,  it  is  free  from  any  unpleasant  or 
dangerous  consequence. 

The  only  other  germicides,  from  which  we  should  be  dis- 
posed to  expect  any  good  results,  are  formalin  and  peroxide  of 
hydrogen.  Of  the  powers  of  formalin  there  is  little  doubt,  but  it 
possesses  the  drawback  that  if  allowed  to  act  for  too  long  on  the 
tissues  it  sometimes  gives  rise  to  extremely  severe  pain.  We 
have  no  personal  experience  of  its  use  in  puerperal  cases,  but, 
judging  from  its  effect  in  subacute  gonorrhceal  infection  of  the 
uterus,  we  believe  that  it  would  prove  of  value  in  both  putrid  and 
septic   endometritis.     Formalin    may  be  used   at  a   strength   of 


9i8  PATHOLOGY  OF  THE  PUERPERIUM 

from  ten  to  forty  per  cent.,  and  should  be  injected  directly  into 
the  uterine  cavity,  to  prevent  it  from  coming  into  contact  with 
lacerations  of  the  vagina  or  cervix,  and  then  should  be  washed 
away  as  soon  as  it  has  acted  for  the  required  time.  If  it  is  used 
at  a  strength  of  forty  per  cent.,  it  should  not  be  allowed  to  act 
for  more  than  thirty  seconds,  but,  if  used  weaker,  it  may  act  for 
a  proportionately  longer  time.  If  it  causes  pain,  it  must  be 
washed  away  immediately,  and  so,  when  it  is  about  to  be 
injected,  the  operator  must  have  a  douche  and  Bozemann's 
catheter  ready  for  immediate  use.  Peroxide  of  hydrogen  may  be 
used  at  a  strength  of  from  thirty  to  fifty  per  cent.,  and  may  be 
added  to  the  douche,  or  directly  injected  into  the  uterus.  On 
meeting  with  the  decomposing  lochia,  oxygen  is  set  free  and  free 
effervescence  occurs.  The  peroxide  should  be  slowly  injected 
until  effervescence  ceases. 

In  all  cases,  the  strength  of  the  patient  must  be  maintained 
by  suitable  food,  and,  if  necessary,  by  the  use  of  stimulants.  If 
the  patient  is  anaemic,  iron  may  be  given  with  advantage,  provided 
that  it  does  not  interfere  with  her  digestion.  The  administration 
of  ergot  is  also  advisable,  as,  by  promoting  uterine  contraction,  it 
hastens  involution,  and  also  lessens  the  absorption  of  toxins  from 
the  uterine  cavity.  A  drachm  of  the  liquid  extract  may  be  given, 
night  and  morning,  for  four  or  five  days. 


SEPTIC  INFECTION 

Any  part  of  the  genital  tract  may  be  the  seat  of  septic  infection, 
provided  that  a  lesion  of  the  mucous  membrane  has  occurred. 
Unfortunately,  such  lesions  invariably  occur  during  delivery,  and 
the  more  extensive  the  lesion  the  greater  the  opportunity  for 
infection.  It  has  already  been  mentioned,  that  primiparae  are 
more  liable  to  puerperal  sepsis  than  multiparae,  owing  in  part  to 
the  greater  rigidity  of  their  tissues,  and  the  consequent  greater 
frequency  of  lacerations.  The  interior  of  the  uterus  offers  a 
favourable  site  for  infection,  as  it  presents,  not  only  at  the  placental 
site,  but  where  the  decidua  have  come  away,  raw  surfaces,  through 
which  bacterial  invasion  can  occur. 

The  classification  of  puerperal  septic  conditions  into  general  and 
local  is  for  clinical  purposes  the  most  convenient.  Pathologically, 
however,  there  is  but  little  justification  for  it,  as  there  is  probably 
no  such  condition  as  a  purely  local  sepsis.  No  matter  how 
localised  an  infection  may  appear  to  be,  it  is  accompanied  in 
many  cases  by  certain  general  results,  as  fever,  headache,  circu- 
latory disturbances  and  leucocytosis,  which  are  the  manifestations 
of  a  general  intoxication.  In  most  cases,  moreover,  it  is  probable 
that  a  general  infection  or  bacteriaemia  occurs,  since  it  is  unlikely 
that  an  infection  by  streptococcus  or  the  colon  bacillus  can  be  long 
continued  without  bacteria  gaining  access  to  the  blood-stream. 


SEPTIC  LESIONS  OF  THE   VULVA  AND   VAGINA  919 

In  spite  of  this,  for  clinical  purposes  the  conventional  classifi- 
cation is  convenient,  and  on  that  account  we  shall  adopt  it. 
Under  the  name  of  local  infections,  we  shall  describe  those 
conditions  in  which  the  local  changes  are  manifest,  and  the 
general  changes  have  not  demonstrated  themselves  by  local 
lesions  elsewhere,  or  by  pronounced  constitutional  symptoms. 
As  general  infections,  will  be  described  those  conditions  in  which 
the  constitutional  effects  are  so  preponderant  as  to  overshadow 
the  lesions  from  which  they  take  origin,  and  those  in  which 
secondar)'  lesions  occur  at  distal  points. 

Local  Septic  Infection. 

Local  infection  of  the  genital  tract  is  perhaps  the  most  common 
form  in  which  puerperal  infection  manifests  itself.  The  extent 
of  the  infected  area  differs  markedly  in  different  cases,  as  the 
infection  may  be  confined  to  a  perinaeal  or  labial  laceration,  may 
extend  to  the  vagina  and  uterus,  or  may  involve  the  entire  genital 
apparatus  and  the  pelvic  cavity.  We  mention  this  lest  the  fact 
that  we  describe  separately  the  effect  of  infection  of  the  individual 
parts  of  the  genital  tract,  might  lead  the  student  to  think  that  in 
practice  he  will  find  infection  strictly  limited  to  such  parts.  Such 
a  limitation  may  occur,  but  it  is  rare. 

Lesions  of  the  Vulva  and  Vagina. — Septic  changes  in  the  vulva 
and  vagina  show  themselves  in  one  of  two  forms,  the  ulcerative 
and  the  inflammatory.  The  ulcerative  form  manifests  itself  as 
the  so-called  puerperal  ulcer,  which  forms  on  the  site  of  lacerations 
or  contusions  the  results  of  injury  during  delivery,  especially 
when  irritating  discharges  remain  in  contact  with  the  part.  It  is 
most  commonly  found  about  the  perinaeum,  the  lower  third  of 
the  vagina,  and  the  labia.  The  ulcer  may  be  bathed  in  a  dirty 
and  ill-smelling  discharge  or  covered  with  a  distinct  diphtheritic 
membrane,  consisting  of  necrosed  tissue  and  coagulated  dis- 
charges. The  surrounding  tissue  shows  the  inflammatory  changes 
which  commonly  take  place  around  an  ulcer.  Bacteriological 
examination  detects  the  presence  of  the  streptococcus  pyogenes, 
together  with  a  host  of  putrefactive  organisms.  The  term 
'  diphtheritic '  applied  to  the  membrane  in  these  cases  is  of 
histological  significance  only,  and  does  not  suggest  the  presence 
of  the  diphtheria  bacillus. 

More  common  than  ulceration  is  the  occurrence  of  a  diffuse 
inflammation  situated  usually  at  the  posterior  commissure  of  the 
vulva  and  in  the  posterior  wall  of  the  vagina.  The  inflam- 
mation is  often  located  in  small  and  scattered  patches,  which,  as 
they  extend  tend  to  coalesce.  These  patches  are  covered  by  a 
white  and  firm  membrane,  composed  almost  entirely  of  fibrinous 
exudate  and  extravasated  leucocytes,  with  a  few  epithelial  cells. 
In  other  cases,  there  is  a  general  catarrh  of  the  vagina  ;  in  the 
earlier  stages  this  is  associated  with  a  swollen  and  red  condition 


920 


PATHOLOGY  OF  THE  PUERPERIUM 


of  the  mucous  membrane,  and  later  with  a  purulent  discharge. 
In  the  most  severe  forms,  a  diphtheritic  slough  forms  over  a  large 
extent  of  mucous  surface. 

Superficial  lymphangitis  may  occur  in  connection  with  vulvar 
infections,  with  consequent  implication  of  the  inguinal  glands. 

Quite  distinct  from  these  streptococcal  infections  is  the  rarer 
condition  of  true  diphtheria  of  the  vulva  and  vagina.  When  this 
occurs  in  these  regions  during  the  puerperium,  it  does  not,  how- 
ever, present  any  special  features  distinct  from  those  presented  at 


Fig.  380. — Uterus  removed  from  a  Patient  who  died  of  Acute  Sepsis. 
Note  the  abnormally  smooth  condition  of  the  endometrium. 

1,  Left  Fallopian  tube;  2,  left  ovary;  3,  os  externum;  4,  right  ovary; 
5,  right  Fallopian  tube.  (From  a  specimen  in  the  Museum  of  the  Rotunda 
Hospital.) 

other  times  or  in  other  situations.    It  is  accompanied  by  the  usual 
general  symptoms  of  diphtheria. 

Lesions  of  the  Uterus. — Although  inflammations  of  the  uterus 
are  not  only  the  most  common,  but  by  far  the  most  serious  of  the 
lesions  due  to  puerperal  infection,  it  is  rarely  that  they  can  be 
correctly  termed  '  local  sepsis,'  as  they  are  usually  associated  with 
a  pronounced  sapraemia  or  with  a  general  infection.  There  are 
two  main  types  of  puerperal  endometritis — putrid  endometritis 
and  septic  endometritis.  The  former  has  been  already  described, 
while  the  latter,  though  more  commonly  associated  with  general 
sepsis  than  with  a  purely  local  condition,  may  conveniently  be 
described  here. 


SEPTIC  LESIONS  OF  THE  UTERUS 


921 


The  septic  type  of  endometritis  in  its  acutest  form  is  due  to 
invasion  of  the  tissues  by  a  virulent  streptococcal  or  staphylo- 
coccal infection.  It  may  attack  any  part  of  the  inside  of  the 
uterus,  and  usually  remains  localised  to  the  area  first  infected.  The 
lochia  may  be  increased  in  quantity,  but  in  the  more  acute  cases 
are  usually  diminished  or  even  absent.  They  may  become  puru- 
lent in  character,  but  are  not  foetid.  The  infection  quickly  spreads 
to  the  deeper  layers  of  the  uterine  wall,  and  obtaining  access  to 
the  lymph  or  blood  stream,  causes  general  and  often  fatal  sep- 
ticaemia.    The  seriousness  of  the  condition  is  due  to  the  danger 


;■;■•*& <;:i&ife,.       ... ,  .  ■■  \ ■  .*..v <#*?;*,« 


Fig.  381. — Puerperal  Endometritis  due  to  Streptococcus  Infection, 
showing  Slight  Development  of  Leucocytic  Wall.     (Williams.) 


of  such  extension,  as  the  local  changes,  even  in  fatal  cases,  are 
remarkably  slight.  The  interior  of  the  uterus  will  be  found  to  be 
quite  smooth,  the  wall  as  a  whole  is  firm,  and  it  is  evident  that 
there  has  been  no  destruction  of  tissue  in  mass  (v.  Fig.  380). 
There  is  consequently  no  tissue  which  could  be  removed  by  the 
curette. 

Microscopic  examination  of  the  endometrium  in  these  cases 
shows  the  nature  of  the  changes  which  are  present.  There  is 
superficially  a  thin  layer  of  necrosed  cells  blended  with  fibrinous 


922 


PATHOLOGY  OF  THE  PUERPERIUM 


exudate,  to  which  the  unnatural  smoothness  is  due.  Immediately 
below  this,  in  the  deeper  layers  of  the  endometrium,  there  is  a 
slight  degree  of  leucocytic  infiltration  (v.  Fig.  381),  which,  in 
amount,  is  in  marked  contrast  to  what  we  have  seen  in  putrid 
endometritis.  Both  toward  the  surface  and  in  the  leucocytic  zone, 
streptococci  are  present  in  large  numbers  (v.  Fig.  382),  and  they 
can  be  also  found  in  the  lymph  channels  which  pass  through  the 
muscular  walls  towards  the  peritoneal  surface.     The  entire  appear- 


"^^5\.  U-uiv\i  ^-%^ 


Fig.  382. — Streptococcic  Endometritis,  showing  Invasion  of 
Leucocytic  Wall,      x  800.     (Williams.) 


ance  points  to  an  attack  so  rapid  that  the  usual  tissue  resistance 
to  bacterial  invasion  has  not  had  time  to  occur. 

The  foregoing  description  applies  rather  to  the  condition  of  the 
uterus  in  a  typical  case  of  acute  general  sepsis  than  to  the  actual 
condition  most  commonly  met  with.  In  the  ordinary  cases  of  less 
virulent  infection,  the  uterus  presents  changes  which  are  inter- 
mediate between  those  just  described  and  those  present  in  putrid 
endometritis.     The  organ  is  large,  its  wall  thickened,  and  its  tissue 


SEPTIC  LESIONS  OF  THE   UTERUS  923 

friable.  The  surface  shows  much  more  marked  changes  than 
in  the  acute  septic  variety,  but  there  is  not  as  much  destruction 
of  tissue  as  in  putrid  endometritis.  The  exudate  is  purulent  and 
often  bloody,  and  consequently  the  lochia  are  increased  in  quantity. 
There  are,  in  fact,  the  usual  results  of  a  severe  catarrh  with  a 
purulent  exudate.  In  some  cases,  the  exudate  contains  a  larger 
number  of  cells  than  does  ordinary  pus,  and  a  distinct  false 
membrane  lining  some  portion  of  the  interior  of  the  uterus 
appears.  To  this  condition  the  term  '  diphtheritic  endometritis  ' 
was  formerly  applied,  and  it  was  described  as  a  distinct  variety.* 
There  is,  however,  no  ground  for  such  a  distinction,  as  no  line 
can  be  drawn  between  it  and  the  other  conditions  we  have 
described. 

In  many  of  the  cases  of  this  intermediate  class,  particularly 
those  most  closely  approaching  putrid  endometritis,  the  colon 
bacillus  is  present,  either  alone,  or  more  commonly  as  one  element 
of  a  mixed  infection.  When  it  is  present,  as  has  been  already 
mentioned,  the  lochia  are  foul  smelling,  and  often  frothy  owing 
to  the  production  of  gas  (v.  Fig.  383). 

In  many  of  these  cases,  putrefactive  organisms  are  also  present 
in  the  uterus.  The  toxins  produced  by  them  facilitate  the 
advance  of  the  parasitic  organisms  into  the  uterine  walls,  or,  in 
other  words,  the  presence  of  a  decomposing  fluid  adds  virulence 
to  comparatively  inactive  pyogenic  germs,  f 

Occasionally,  a  very  mild  form  of  septic  infection  occurs  with- 
out general  symptoms  of  importance  following.  In  such  cases, 
the  inflammation  is  in  the  form  of  a  slight  catarrh,  and  the  lochia 
are  at  first  diminished,  but  afterwards  increased.  This  form  may 
result  from  direct  extension  of  a  catarrh  of  the  vagina,  and  is 
due  to  the  presence  of  the  staphylococcus  aureus.  Some  of  these 
cases  present  a  close  resemblance  to  the  diphtheritic  form  just 
mentioned. 

Where  endometritis  results  from  gonococcal  infection  it  is 
usually  mild  in  character,  and  is  often  unaccompanied  by  general 
symptoms.  j 

In  most  cases  of  endometritis  of  septic  origin,  an  extension  of 
the  infection  into  the  muscular  coat  of  the  uterus  occurs.  Such 
a  metritis  is  not  a  separate  condition,  but  is  merely  an  extension 
of  the  infective  process  already  described.  In  some  cases,  how- 
ever, a  metritis  of  a  different  kind  occurs.  During  their  passage 
through  the  lymphatics  of  the  uterine  wall,  bacteria  may  become 
lodged  at  any  point,  and  there  give  rise  to  segregated  foci  of 
inflammation,  possibly  resulting  in  abscess  formation,  either  in 
the  muscle,  or,  more  frequently,  between  the  muscle  and  the 
peritoneal  covering. 

*  Hervieux,  '  Traite  des  Maladies  Puerperales,' p.  240 ;  '  American  Text- 
book of  Obstetrics,'  vol.  ii.,  p.  694. 

t  Edgar,  '  Practice  of  Obstetrics,'  p.  464. 

X  Ibid.,  p.  777;  Varnier,  '  Obstetrique  Journaliere,'  p.  413  et  scq. 


924 


PATHOLOGY  OF  THE  PUERPERIUM 


When  thrombi  form  in  the  uterine  veins  at  the  placental  site, 
as  sometimes  happens,  they  are  very  liable  to  become  infected, 
and  give  rise  to  a  condition  of  phlebitis  (v.  Fig.  384).  This  is 
most  likely  to  occur  when  such  procedures  as  the  manual  detach- 
ment of  the  placenta  have  been  performed.     Phlebitis  may  also 


.....■-- 


Fig.  383. — Uterus  removed  from  a  Patient  who  died  of  Mixed 
Septic  and  Saprophytic  Infection. 

Note  the  rough  and  necrotic  lining  of  the  cavity. 

1,  Fallopian  tube;  2,  ovary;  3,  os  externum;  4,  vagina.      (From  a  specimen 
in  the  Museum  of  the  Rotunda  Hospital.) 

arise  apart  from  the  occurrence  of  thrombosis,  by  the  spreading  of 
inflammation  to  the  walls  of  the  veins  from  the  tissues  surround- 
ing them.  If  the  organisms  are  virulent,  abscesses  may  occur 
along  the  veins,   and    so   a    condition  arise  very  similar  to  the 


THE  EXTRA-UTERINE  PELVIC  LESIONS  OF  SEPSIS 


925 


suppurative  metritis  already  described  as  resulting  from  lymphatic 
infection.  More  important  results,  however,  are  spreading  phle- 
bitis, pelvic  cellulitis  and  general  pyaemia,  of  which  mention  will 
presently  be  made. 

Extra-uterine  Pelvic  Lesions. — When  bacteria  have  infected  the 
uterus  they  may  pass  to  the  parts  surrounding  it  by  one  of  several 
paths.  They  may  travel  directly  along  the  Fallopian  tubes, 
causing  inflammation  as  they  go.  They  may  pass  by  means  of 
the  veins,  either  by  an  extending  phlebitis,  or  by  the  breaking  off 
from  a  thrombus  of  infective  emboli.  Finally,  they  may  be 
carried  directly  through  the  uterine  walls  in  the  lymph  spaces 
and  lymphatic  vessels.     We  shall  see  that  infection  by  each  of 


ST... 

V* 

N 

*• 

t 

*q£ 

*-*v  v~ 

V 

'%. 

A 

~.,. 

'    %" 

\   '' 

.X 

\><fc, 

' 

- 

I   I 


•*. 


Fig.  384. — Section  through  a  Thrombosed  Pelvic  Vein,  showing 
Streptococci,      x  800.     (Williams.) 


these  paths  actually  occurs,  the  resulting  lesions  differing  in  each 
case. 

Salpingitis  and  Oophoritis. — Salpingitis  occurs  when  the  infec- 
tion travels  directly  from  the  uterine  cavity  to  the  tubes.  It  is 
catarrhal  in  nature,  with,  in  severe  cases,  a  purulent  exudate. 
When  it  is  the  result  of  a  gonococcal  infection,  it  occurs  late  in 
the  puerperium. 

Oophoritis  is  not  common,  but  the  infection  may  be  carried  to 
the  ovary  either  by  lymphatic  channels  from  the  uterus,  or  by 
direct  extension  from  an  infected  Fallopian  tube.  The  ovary 
becomes  enlarged  and  cedematous,  and  may  be  the  seat  of 
numerous  small  abscesses,  or  its  parenchyma  may  be  destroyed 
and  a  single  abscess  cavity  result. 

Pelvic  Cellulitis. — One  of  the  commonest  results  of  inflammation 
of  the  uterus  is  involvement  of  the  peri-uterine  connective  tissue, 
or  parametritis.  The  micro-organisms  reach  the  part  through  the 
lymphatics  coming  from  an  area  of  infection  in  the  uterus  or 
cervix.     In  some  instances,  the  condition  springs  from  phlebitis 


926  PATHOLOGY  OF  THE  PUERPERIUM 

which  has  spread  to  the  pelvic  veins.  The  resulting  inflammation 
shows  itself  by  oedema  and  possibly  by  thrombosis,  often  followed 
by  suppuration.  The  lymphatic  glands  of  the  sacral  and  internal 
iliac  groups  are  always  affected,  and  suppuration  may  begin  in 
them  ;  not  infrequently  the  lumbar  chain  of  glands  is  also  affected. 
The  suppuration,  whether  originating  in  the  glands  or  in  the 
cellular  tissue,  is  often  considerable  in  extent,  and  a  large 
burrowing  abscess  may  form.  If  unopened  this  may  burst  into 
the  peritoneum,  or  into  one  of  the  hollow  viscera  in  the  neighbour- 
hood ;  or,  more  commonly,  remaining  in  the  connective  tissue,  it 
may  make  its  way  to  the  surface,  and  point  in  the  groin,  the  iliac 
region,  or  above  the  pubis.  Cases  have  been  recorded  where  a 
burrowing  abscess  has  ascended  behind  the  peritoneum  until  it 
penetrated  the  diaphragm  and  reached  the  thorax. 

Pelvic  Peritonitis. — This  condition  may  arise  in  various  ways. 
The  most  common  is  by  the  direct  passage  of  bacteria  through 
the  lymphatics  of  the  uterus,  and  inflammation  originating  in  this 
way  is  a  very  frequent  result  of  septic  endometritis.  A  similar 
condition  may  follow  infection  of  the  vagina  or  cervix.  On  the 
other  hand,  local  peritonitis  may  be  secondary  to  cellulitis,  and 
may  occur  either  by  direct  extension  of  the  infective  process,  or 
as  a  result  of  the  rupture  of  a  pelvic  abscess.  In  rarer  instances, 
infection  reaches  the  peritoneal  surface  along  the  course  of  the 
Fallopian  tubes. 

Pelvic  peritonitis,  or,  as  it  is  sometimes  called,  perimetritis,  never 
occurs  without  some  degree  of  associated  cellulitis,  so  that  one 
meets  together  the  changes  due  to  inflammation  of  serous  mem- 
brane, and  of  subserous  tissue.  Its  most  common  seat  is  the 
pouch  of  Douglas  and  the  posterior  uterine  wall.  The  changes 
undergone  by  the  serous  membrane  vary  greatly  in  degree.  In 
the  milder  cases,  the  peritoneum  and  underlying  tissues  become 
sodden  and  cedematous,  and  a  fibrinous  exudate  appears  on  the 
surface.  Adhesions  rapidly  form  between  the  peritoneal  surfaces 
of  the  uterus,  rectum,  and  small  intestine.  The  last-named 
becomes  glued  to  the  pelvic  viscera,  and  the  parts  are  densely 
matted  together. 

In  severer  cases,  the  exudate  is  of  a  more  cellular  character,  and 
forms  a  membrane  over  the  affected  surfaces.  If  the  process 
continues,  these  surfaces  are  finally  bathed  in  pus,  which  tends  to 
collect  in  the  pouch  of  Douglas,  or,  in  some  cases,  in  the  utero- 
vesical  fossa.  .If  the  infection  is  to  remain  local,  the  pus  must 
become  encysted,  and  this  end  is  aided  by  the  adhesions  which 
have  already  formed.  Even  after  a  collection  of  pus  becomes 
circumscribed,  a  sudden  exertion  or  other  cause  may  break  down 
the  adhesions,  and  general  peritoneal  infection  follow. 

Cystitis. — Among  the  local  manifestations  of  puerperal  sepsis 
it  is  necessary  to  mention  one  other  pelvic  infection  not  uncommon 
in  the  puerperal  state,  namely,  inflammation  of  the  bladder.  In 
some  cases  infection  of  the  bladder  is  secondary  to  that  of  the 


GENERAL  PERITONITIS  927 

vulva,  from  which  it  either  travels  by  direct  extension  through 
the  urethra,  or  is  carried  to  the  bladder  on  a  catheter.  If  the 
infection  spread  by  the  urethra,  catarrh  of  that  duct  is  also 
present.  Cystitis  may,  however,  occur  without  any  obvious 
vulvar  infection,  the  bacteria  being  carried  to  the  bladder  on  a 
dirty  catheter.  The  active  organism  is  most  commonly  the 
colon  bacillus.  Having  reached  the  bladder,  the  infection  may 
extend  to  the  ureters  and  pelvis  of  the  kidney.  In  rare  cases, 
infection  passes  to  the  bladder  from  an  antecedent  pelvic  cellulitis 
or  peritoneal  infection. 

General  Peritonitis. — The  classification  of  general  peritonitis 
presents  some  difficulty,  as  it  is  doubtful  whether  it  should 
be  treated  as  a  local  lesion  spreading  from  the  pelvis,  or  as  a 
manifestation  of  a  general  condition.  It  occurs  in  both  of  these 
relations,  but  at  present  we  are  alone  concerned  with  the  former. 

General  peritonitis,  as  an  inflammation  of  local  origin,  may  rise 
by  the  extension  of  an  infection  occurring  in  any  of  the  pelvic  sites 
enumerated.  Most  commonly,  it  is  either  an  extension  through 
the  lymphatics  of  an  acute  septic  endometritis,  or  else  a  direct 
extension  of  a  pelvic  peritonitis.  In  the  latter  case,  it  may  be 
due  to  the  sudden  breaking  of  the  adhesions  circumscribing  a 
suppurating  focus.  The  rupture  of  a  cellular,  tubal,  or  other 
abscess  into  the  peritoneum,  brings  about  a  similar  result. 

In  the  most  acute  cases  of  peritonitis,  death  may  result  before 
there  is  time  for  any  noticeable  anatomical  change  to  take  place. 
The  peritoneum  will  be  found,  however,  to  contain  a  thin, 
blood-stained  serum,  which  swarms  with  bacteria.  More  often  a 
distinct  inflammatory  reaction  will  have  taken  place.  The  entire 
peritoneal  surface  will  be  covered  with  a  purulent  and  milk-like 
exudate,  in  which  the  intestines  are  bathed.  If  the  exudate  is 
more  fibrinous,  it  will  appear  as  a  false  membrane,  and  adhesions 
will  be  present.  When  a  fluid  exudate  is  in  process  of  absorp- 
tion, curd-like  flakes  are  found  lying  between  the  viscera.  In  case 
the  inflammation  has  spread  from  a  pelvic  focus  and  is  not  due  to 
rapid  lymphatic  infection,  these  changes  are  always  well  marked. 
General  peritonitis,  by  extension  through  the  diaphragm,  occa- 
sionally gives  rise  to  pleuritis  or  pericarditis. 

Symptoms. — The  symptoms  of  local  septic  infection  are,  accord- 
ing to  the  nature  of  the  particular  case,  those  of  acute  septic 
vaginitis,  endometritis,  salpingitis,  or  pelvic  peritonitis  or  cellulitis 
as  the  case  may  be. 

In  septic  vaginitis  and  vulvitis,  the  vulva  and  vagina  are 
swollen,  inflamed,  cedematous,  and  exceedingly  tender.  Usually, 
on  examination,  one  or  more  puerperal  ulcers  will  be  found, 
corresponding  to  lacerations  of  the  mucous  membrane.  In  a 
very  acute  case,  the  patient  may  be  unable  to  endure  the  intro- 
duction of  even  one  finger  or  of  the  nozzle  of  the  douche  into  the 
vagina. 

The  local  symptoms  of  acute  septic  endometritis  are  not  very 


928  PATHOLOGY  OF  THE  PUERPERIUM 

clearly  distinguishable  from  those  of  putrid  endometritis,  and  the 
distinction  is  the  more  difficult  to  make  in  that,  in  the  majority  of 
cases,  the  infection  is  '  mixed '  saprophytic  and  septic.  In  a 
purely  septic  infection,  the  lochial  discharge  lacks  the  offensive 
odour  which  is  characteristic  of  decomposition,  and  consists  in 
great  part  of  pus,  with  which  a  varying  quantity  of  blood  is  mixed. 
Uterine  involution  ceases,  and  the  uterus  is  perhaps  more  tender 
than  in  the  case  of  saprophytic  infection.  If  the  discharge  is 
examined  bacteriologically,  colonies  of  the  invading  bacterium 
will  be  found.  In  a  mixed  infection,  the  discharge  is  similar  to 
that  which  is  present  in  putrid  endometritis.  The  constitutional 
symptoms  are  also  very  similar  to  those  of  the  latter  condition, 
save  that,  as  a  rule,  the  temperature  is  higher  and  the  pulse-rate 
is  more  rapid  in  proportion  to  the  temperature.  Both  of  these 
differences,  however,  largely  depend  upon  the  nature  of  the 
invading  organism.  In  septic  endometritis,  rigors  may  occur,  but 
as  a  rule  these  are  the  result  of  the  extension  of  the  infection  to 
hitherto  exempted  tissues,  and  not  of  the  endometritis. 

The  extension  of  infection  beyond  the  uterus  into  the  tubes,  the 
parametrium,  and  the  peritoneal  cavity  is  shown  by  an  increase  in 
the  severity  of  the  symptoms,  the  occurrence  of  rigors,  and  of  a 
varying  degree  of  pain.  If  the  infection  remains  localised  to  the 
pelvic  cavity,  the  pain  is  more  marked,  and  is  usually  due  to  the 
formation  of  limiting  adhesions  between  the  intestines  and  the 
pelvic  peritoneum.  In  such  cases,  the  lower  part  of  the  abdomen 
is  extremely  tender,  and,  even  from  the  first,  a  sense  of  increased 
resistance  can  be  felt  over  the  infected  area.  As  the  results  of 
the  extension  of  the  infection  become  more  marked,  this  resistance 
hardens  into  a  definite  swelling,  which  can  be  felt  either  by  placing 
the  hand  on  the  lower  part  of  the  abdomen  or  by  making  a 
vaginal  examination.  The  situation  of  this  swelling  depends 
upon  the  course  the  infection  has  taken,  and  has  been  already 
described.  If  the  infection  extends  into  the  general  peritoneal 
cavity,  the  abdomen  becomes  distended  and  tympanitic,  owing 
to  paralysis  of  the  intestines,  and  for  the  same  reason  there  is 
usually  complete  constipation.  In  these  cases,  pain  is  as  a  rule 
absent.  The  constitutional  symptoms  are  very  similar  to  those 
of  acute  lymphatic  sepsis. 

Diagnosis. — Accurate  diagnosis  of  the  nature  and  the  extent  of 
local  septic  infection  is  of  the  most  far-reaching  importance.  In 
order  to  effect  it,  three  facts  must  be  ascertained.  The  first  of 
these  is  the  nature  of  the  invading  organism,  and,  to  ascertain 
this,  in  all  cases  of  infection  a  portion  of  the  discharge  should  be 
collected,  with  due  precautions  from  the  interior  of  the  uterus, 
and  examined  bacteriologically.  The  chief  object  of  the  bacterio- 
logical examination  is  to  ascertain  the  presence  or  absence  of 
staphylococci  and  streptococci,  as  the  presence  of  saprophytic 
organisms  in  any  numbers  can  be  determined  from  the  odour 
and  appearance  of  the  lochia.     We  thus  ascertain  whether  the 


TREATMENT  OF  LOCAL  INFECTION  929 

infection  is  purely  saprophytic,  '  mixed,'  or  septic.  The  second 
fact  is  the  condition  of  the  interior  of  the  uterus.  To  ascer- 
tain this,  the  hnger  should  be  introduced  and  the  condition  of 
the  endometrium  carefully  examined  with  a  view  to  determining 
whether  portions  of  placenta  or  membranes  have  been  left  behind, 
and  whether  the  endometrium  is  smooth  or  rough  and  shaggy. 
The  third  fact  is  the  extent  to  which  the  infection  has  extended, 
beyond  the  uterus.  The  diagnosis  of  the  extension  of  septic 
infection  beyond  the  uterus  can  be  made  from  the  increased 
severity  of  the  symptoms,  the  increased  pain,  the  presence  of 
rigidity  and  increased  tenderness  to  one  or  other  side  of  the  uterus, 
and,  later,  the  presence  of  a  definite  swelling.  The  existence  of 
general  peritoneal  infection  is  shown  by  a  still  more  marked 
increase  in  the  severity  of  the  symptoms,  the  distended  condition 
of  the  abdomen,  intestinal  paralysis,  the  characteristic  appearance 
of  the  tongue,  and  the  general  aspect  of  the  patient. 

Treatment. — The  correct  treatment  of  local  septic  infection  of 
the  genital  tract  after  delivery  is  still  the  subject  of  discussion. 
Many  writers,  and  notably  Pryor  of  New  York,*  advocate  the 
adoption  of  heroic  measures,  to  which  we  shall  presently  refer. 
Others  advise  the  adoption  of  less  heroic  measures,  the  chief  of 
which  are  repeated  douching,  and  curetting  of  the  infected  uterus. 
In  this  class  are  found  the  majority  of  British  obstetricians. 
Still  others,  and  notably  Bumm  and  Whitridge  Williams,!  con- 
sider that  curetting  as  a  routine  measure  is  by  no  means  to  be 
recommended,  and  that  repeated  intra-uterine  douching,  especially 
in  streptococcal  infection,  is  not  only  useless  but  perhaps  harmful. 
In  the  face  of  these  diverse  opinions,  for  all  of  which  those  who 
hold  them  can  produce  supporting  statistics,  it  is  unwise  to 
attempt  to  dogmatise,  and  we  shall  content  ourselves  with  de- 
scribing the  treatment  we  consider  to  be  most  suitable. 

The  treatment  of  purely  saprophytic  infection  has  been  already 
described,  and,  in  our  opinion,  the  local  treatment  of  a  '  mixed ' 
infection  should  be  very  similar.  The  treatment  of  a  purely 
septic  infection  is,  however,  another  matter,  and,  in  deciding  upon 
the  course  to  adopt,  we  should  be  guided  by  the  condition  of  the 
interior  of  the  uterus.  If  the  endometrium  is  shaggy,  and  small 
portions  of  retained  placenta,  membranes,  and  decidua  are 
adherent  to  it,  they  should  be  gently  removed  with  the  finger  or 
with  a  blunt  curette,  and  the  uterus  then  plugged  with  iodoform 
gauze.  This  plug  must  be  removed  at  the  end  of  twelve  hours, 
and,  if  necessary,  a  fresh  one  inserted  after  first  douching  out 
the  cavity.  If,  on  the  other  hand,  the  inside  of  the  uterus  is 
quite  smooth,  a  condition  that  is  found  in  the  most  acute  forms 
of  streptococcal  infection,  curetting  is  contra-indicated,  and  the 
douche  and  the  plug  are  probably  useless.  In  these,  and  indeed 
in  all  forms  of  local  septic  infection  of  the  uterus,  we  should  be 

*  '  The  Treatment  of  Pelvic  Inflammation,'  p.  34.     Philadelphia,  1899. 
f  'Obstetrics,'  p.  786.     New  York,  Appletcn  and  Co.,  1903. 

59 


930  PATHOLOGY  OF  THE  PUERPERIUM 

inclined  to  practise  the  injection  of  a  strong  solution  of  formalin 
(from  twenty  to  forty  per  cent.)  into  the  uterine  cavity.  The 
formalin  should  be  quickly  injected  in  sufficient  quantity  to  ensure 
its  reaching  the  entire  surface  of  the  endometrium,  i.e.,  from  two 
to  four  drachms,  and  washed  out  after  fifteen  to  thirty  seconds 
have  elapsed.  The  penetrating  power  of  formalin  is  considerable, 
and  our  experience  of  its  use  in  non-puerperal  cases  leads  us  to 
believe  that  injected  in  the  manner  we  have  described  it  would 
not  produce  any  harmful  effect  upon  the  patient,  and  would  exert 
a  deterrent  effect  on  the  development  of  the  invading  micro- 
organism. 

In  cases  in  which  infection  has  extended  beyond  the  uterus  into 
the  parametrium,  the  tubes,  or  the  pelvic  cavity,  our  treatment, 
at  first  at  all  events,  must  be  palliative,  and  constitutional.  Hot 
fomentations  over  the  lower  part  of  the  abdomen,  and  hot  vaginal 
douches  given  at  a  low  pressure,  will  help  to  relieve  pain.  Hypo- 
dermic injections  of  morphia  may  be  also  necessary  with  the 
same  object.  Later,  if  pus  forms,  it  must  be  evacuated.  When 
it  forms  in  Douglas'  pouch,  or  the  parametrium,  or  in  tubes  which 
have  prolapsed  into  Douglas'  pouch,  this  can  be  done  best  through 
the  posterior  vaginal  fornix.  Occasionally,  the  abscess  cannot  be 
reached  from  below,  and  may  extend  upwards  until  it  comes  to 
point  on  the  abdominal  wall,  usually  a  short  way  above  Poupart's 
ligament.     In  such  cases,  it  must  be  opened  where  it  points. 

If  general  septic  peritonitis  occurs,  surgical  intervention,  at  the 
earliest  moment,  affords  the  only  hope  of  relief.  In  such  cases, 
the  abdomen  must  be  opened,  thoroughly  washed  out  with  saline 
solution,  and  drained  both  through  the  floor  of  Douglas'  pouch 
into  the  vagina,  and  through  the  abdominal  wound. 

As  we  have  mentioned,  much  more  radical  measures,  than 
those  we  have  described,  are  recommended  by  various  writers. 
Of  these  measures,  the  two  most  important  are  the  opening  of 
the  posterior  fornix  of  the  vagina  and  the  drainage  of  Douglas' 
pouch,  and  hysterectomy.  Pryor,  so  far  as  we  know,  is  respon- 
sible for  the  introduction  of  the  former  of  these  procedures.  His 
practice  consists  in  curetting  the  uterus  in  all  cases  in  which  he 
considers  that  septic  organisms  have  passed  deeply  into  the 
uterine  tissues,  and  in  opening  into  Douglas'  pouch  whenever  he 
curettes  the  uterus.  He  then  breaks  down  any  adhesions  that 
may  have  formed  and  plugs  Douglas'  pouch  with  iodoform  gauze. 
We  consider  that  such  a  procedure  is  rational  and  suitable,  when 
we  know  that  infection  has  extended  into  Douglas'  pouch,  and 
when  such  infection  has  been  shut  off  by  adhesions  from  the 
general  peritoneal  cavity.  On  the  other  hand,  we  cannot  regard 
it  as  either ' scientific  or  wise  in  cases  in  which  there  is  no  reason 
to  believe  that  Douglas'  pouch  is  infected,  or  in  which  it  establishes 
an  opening  into  the  general  peritoneal  cavity.  The  performance 
of  hysterectomy  in  cases  of  acute  puerperal  infection  of  the  uterus 
does  not  appear  to  us  to  be  an  operation  with  any  future  before  it, 


LYMPHATIC  SEPSIS  931 

although  it  has  been  recommended  and  successfully  practised  by 
several  distinguished  operators.  It  is  conceivable  that  occasion- 
ally a  life,  which  would  have  been  otherwise  lost,  might  be  saved 
by  such  a  procedure,  but  the  difficulty  of  determining  the  type  of 
case,  in  which  such  a  result  might  be  obtained,  is  to  our  mind 
insuperable,  and  in  many  cases  instead  of  improving  it  must 
prejudice  the  prospect  of  recovery.  If  the  operation  is  to  offer 
a  fair  prospect  of  success,  it  must  be  undertaken  before  the 
infection  has  spread  beyond  the  uterus,  but  to  perform  it  in  all 
cases  of  uterine  infection  would  mean  the  mutilation  and  even  the 
death  of  many  patients  who  might  have  recovered  if  simpler 
measures  had  been  adopted. 

The  constitutional  treatment  of  local  septic  infection  consists  in 
the  maintenance  of  the  patient's  strength  in  every  way  possible. 
The  free  administration  of  stimulants,  and  of  such  drugs  as  iron, 
strychnine,  and  digitalis  when  the  condition  of  the  heart  neces- 
sitates their  use.  The  administration  of  ergot  is  also  indicated, 
with  the  object  of  promoting  uterine  contraction,  and  so  lessening 
the  absorption  of  toxins  from  the  uterus.  The  bowels  must  be 
made  to  act  regularly.  If  the  temperature  attains  a  very  high 
range,  it  should  be  brought  down  by  cold  sponging  or  the  cold 
pack.  If  the  infection  is  streptococcal,  the  use  of  anti-strepto- 
coccic  serum  and  the  subcutaneous  injection  of  saline  solution 
may  be  advisable.  These  measures  will  be  discussed  when  we 
are  considering  lymphatic  sepsis. 

General  Septic  Infection. 

The  systemic  septic  infections  of  the  puerperium  spread  by  one 
of  two  channels — the  lymphatic  vessels,  or  the  veins. 

Septicemia  or  Lymphatic  Sepsis. — In  lymphatic  sepsis,  the 
micro-organisms  have  made  their  way  from  the  endometrium,  or 
from  some  other  focus  of  infection,  into  the  lymph-spaces.  If 
possessed  of  sufficient  resistance  to  overcome  the  bacteriolytic 
powers  of  the  lymph,  they  are  rapidly  carried  upward  through  the 
main  lymph  channels  and  discharged  into  the  blood-stream.  By 
this  means,  they  are  carried  into  all  parts  of  the  body,  and,  if  the 
case  is  severe,  they  can  be  separated  from  the  circulating  blood 
or  body  fluids.  In  the  most  extreme  cases,  such  as  those  due 
to  virulent  streptococcal  infections,  anatomical  changes  are 
almost  entirely  absent,  as  the  patient  succumbs  rapidly  to  the 
toxins  produced.  In  cases  of  less  virulence,  the  microscopic  con- 
ditions already  described  as  typical  of  acute  septic  endometritis 
are  noticeable  locally,  and  sero-sanguineous  effusions  into  the 
peritoneal,  pleural,  and  pericardial  cavities  are  frequently  ob- 
served, the  effused  fluid  swarming  with  bacteria,  while  the  serous 
membranes  may  present  punctate  haemorrhages.  The  latter 
appearance  is  also  common  in  the  pia  mater,  and  may  be  found 

59—2 


932  PATHOLOGY  OF  THE  PUERPERIUM 

both  in  the  large  and  small  intestine.  The  spleen,  liver,  and 
lungs  are  large  and  soft,  being  congested  and  cedematous.  The 
muscles  are  probably  of  darker  colour  than  normal.  The  blood 
shows  marked  leucocytosis,  it  does  not  coagulate  easily,  and  it 
is  of  a  tar-like  consistency. 

An  occasional  manifestation  of  lymphatic  sepsis,  and  one  which 
is  of  importance  from  a  diagnostic  point  of  view,  is  a  general 
erythema  closely  resembling  the  rash  of  scarlatina. 

It  cannot  be  too  strongly  impressed  on  the  mind  that  the 
danger  in  lymphatic  sepsis  lies  in  the  intoxication  produced  by 
bacterial  products,  and  not  in  the  anatomical  injuries  due  to  the 
direct  attack  of  the  bacteria.  The  anatomical  changes  are  only 
of  importance  as  marking  how  widely  the  infection  has  been  dis- 
tributed. It  is  obvious  that,  the  greater  the  number  of  bacteria 
present,  assuming  equality  of  virulence,  the  greater  the  amount 
of  toxins  produced,  and  therefore  the  more  serious  the  condition 
of  the  patient. 

It  is  impossible  to  speak  with  certainty  of  the  mode  of  action 
by  which  the  toxins  are  able  to  destroy  life,  since  their  chemical 
relations  are  by  no  means  clear.  It  is  usual  to  class  them 
with  the  albumins  under  the  name  of  '  toxalbumins,'  but  it  is 
questionable  whether  they  can  be  all  thus  grouped.  Each  race 
of  pathogenic  organisms  seemingly  produces  a  specific  toxin, 
whose  effect  is  part  of  the  effect  produced  by  inoculation  with 
the  organism  itself. 

Symptoms. — The  symptoms  of  lymphatic  sepsis  commence  on 
the  second  or  third  day  after  inoculation,  and,  as  a  rule,  are  well 
marked.  They  are  usually  ushered  in  by  a  severe  rigor,  after 
which  the  temperature  may  rise  to  between  1030  F.  and  1050  F., 
and  the  pulse-rate  increase  to  between  120  and  140.  The  patient 
may  at  first  sweat  profusely,  but  subsequently,  as  the  toxaemic 
condition  becomes  more  marked,  the  skin  becomes  dry.  Rigors 
may  recur  at  intervals,  and  after  each  the  temperature  rises  to  a 
higher  level.  The  lochia  and  milk  may  never  appear,  or,  if  they 
have  appeared,  may  cease.  The  aspect  of  the  patient  is  charac- 
teristic. She  looks  extremely  ill,  her  face  pinched  and  slightly 
jaundiced,  her  eyes  sunk  into  their  sockets,  and  the  angles  of  the 
mouth  and  nose  drawn  down.  A  common  symptom  is  extreme 
depression,  and,  in  cases  of  comparatively  mild  infection,  this 
may  be  the  first  symptom  to  appear.  In  very  virulent  infection, 
on  the  other  hand,  the  patient  may  say  that  she  feels  well,  and 
be  cheerful,  and  even  express  a  wish  to  be  allowed  out  of  bed. 
This  condition  is  known  as  euphoria,  and  is  due  to  the  dulling  of 
the  higher  centres  by  the  bacterial  toxins  that  are  circulating  in 
the  system.  In  some  cases,  an  acute  general  peritonitis  may 
occur  concurrently  with  the  general  systemic  infection.  The 
temperature  tends  to  maintain  a  steady  upward  range,  until  it 
finally  reaches  a  height  of  1060  F.  or  1070  F.,  and  the  pulse  to 
become  more  and  more  rapid  and  weaker.     Finally,  the  patient 


TREATMENT  OF  LYMPHATIC  SEPSIS  933 

sinks  into  a  state  of  unconsciousness,  and  death  soon  occurs. 
The  duration  of  the  disease  in  fatal  cases  is  rarely  more  than  four 
or  five  days,  but  it  may  last  a  week. 

Diagnosis. — The  diagnosis  of  lymphatic  sepsis  can  be  made  from 
the  high  range  of  the  pulse  and  temperature,  the  absence  of 
evidence  of  local  septic  or  saprophytic  infection,  and  the  general 
appearance  of  the  patient.  If  the  lochial  discharge  is  examined 
bacteriologically,  it  will  usually  be  possible  to  find  streptococci, 
and,  occasionally,  they  may  be  found  also  in  the  blood. 

An  appliance  devised  by  Doderlein  will  be  found  very  con- 
venient for  obtaining  lochia  from  within  the  uterus.  It  consists 
of  a  piece  of  slightly  bent  glass  tubing,  eight  inches  in  length,  of 
the  calibre  of  an  ordinary  lead-pencil,  and  with  open  ends.  It  is 
placed  inside  a  larger  glass  tube,  and  both  are  sterilised.  When 
required  for  use  it  is  removed  from  the  larger  tube,  and,  with  the 
aid  of  a  speculum  and  volsellum,  the  bent  end  is  passed  through 
the  cervix,  which  has  been  first  carefully  wiped  with  sterile  wool. 
The  other  end  of  the  tube  is  now  connected  with  a  syringe  by 
means  of  a  rubber  tube,  and  suction  applied.  Some  of  the 
contents  of  the  uterus  enter  the  tube,  which  is  then  removed, 
and  both  ends  having  been  at  once  closed  with  sealing-wax,  it  is 
despatched  to  a  laboratory  for  investigation. 

Treatment. — The  treatment  of  acute  lymphatic  sepsis  is,  so  far, 
most  unsatisfactory.  For  a  time,  it  was  hoped  that  the  introduc- 
tion of  Marmorek's  serum  would  prove  of  value,  but  experience 
has  not  supported  this  belief.  A  committee  appointed  by  the 
American  Gynaecological  Society*  inquired  exhaustively  into  the 
results  obtained  by  the  use  of  this  serum,  and  reported  that  they 
could  find  nothing  in  clinical  or  experimental  literature,  or  in 
their  own  experience,  to  indicate  that  the  employment  of  the 
serum  will  materially  improve  the  general  results  in  the  treat- 
ment of  streptococcal  puerperal  infection.  .  Local  measures,  as 
douching  and  curetting,  have  been  found  to  be  valueless,  as  is 
only  to  be  expected  when  the  extent  of  the  infection  is  taken  into 
account. 

Our  treatment  must  be,  in  the  main,  symptomatic,  and  be 
especially  directed  to  maintaining  the  strength  of  the  patient. 
With  this  object,  alcohol  should  be  given  in  the  largest  doses 
possible  up  to  even  sixteen  or  twenty  ounces  in  the  twenty-four 
hours.  Strychnine  and  digitalis  may  also  be  given  either  hypo- 
dermically  or  by  the  mouth,  with  the  object  of  strengthening 
and  maintaining  the  action  of  the  heart.  If  the  temperature 
rises  above  1050  F.,  it  should  be  reduced,  if  possible,  by  sponging 
with  cold  water,  or  by  a  cold  pack.  The  administration  of 
quinine  and  suchlike  antipyretics  is  of  little  or  no  value.  Sub- 
cutaneous or  intravenous  injections  of  saline  solution,  on  the  other 
hand,  have  sometimes  proved  of  use.  From  one  to  three  pints 
should  be  injected  at  the  time,  and  repeated  every  twelve  hours, 
*  Trans,  of  the  American  Gynecological  Society,  1899,  vol.  xxiv.,  p.  80. 


934  PATHOLOGY  OF  THE  PUERPERIUM 

or  even  more  frequently  if  they  appear  to  produce  a  good  effect. 
If  it  is  decided  to  give  anti-streptococcic  serum  a  trial,  a  first 
injection  of  20  c.cs.,  is  administered,  and  then  10  c.cs.  every 
twelve  hours,  until  a  considerable  improvement  is  manifested. 
As  soon  as  this  occurs,  the  amount  and  the  frequency  of  the 
injections  may  be  diminished.  When  using  the  serum,  strict 
precautions  must  be  taken  to  ensure  the  asepsis  of  the  syringe 
with  which  it  is  injected,  and  of  the  skin  through  which  the 
puncture  is  made. 

Of  late  years,  the  value  of  a  '  polyvalent '  serum,  that  is  a 
serum  prepared  from  a  horse  which  has  been  inoculated  from 
several  different  strains  of  streptococcus,  has  been  the  subject  of 
enquiry.  Van  de  Velde  and  Peham*  have  prepared  polyvalent 
serums  from  strains  of  streptococcus  obtained  from  different 
varieties  of  streptococcal  infection  such  as  erysipelas,  general 
sepsis,  peritonitis,  etc.,  and  have  obtained  good  results.  Fouler- 
ton  f  and  Bonney,  on  the  other  hand,  have  prepared  a  serum  from 
strains  obtained  from  different  cases  of  '  puerperal  fever,'  and  in 
two  cases  of  very  acute  streptococcal  infection,  the  use  of  their 
serum,  prepared  from  five  different  strains,  was  followed  by  good 
results.  The  manner  in  which  antistreptococcic  serum  produces 
its  effect  is  not  clear,  as  is  shown  by  the  fact  that  while  Peham 
considers  that  it  acts  as  a  bactericide  and  checks  the  growth  of 
the  bacteria,  but  does  not  exert  any  actual  antitoxic  action, 
Foulerton  regards  its  action  as  purely  antitoxic.  The  latter 
writer  lays  particular  stress  on  the  dosage,  and  considers  that 
the  initial  dose  must  be  large,  and  that  injections  must  be  sub- 
sequently repeated  until  the  symptoms  of  infection  cease.  He 
advises  to  commence  with  an  initial  injection  of  at  least  twenty 
cubic  centimetres,  and  to  repeat  it,  if  necessary,  at  least  once  in 
every  twenty-four  hours. 

The  value  of  a  polyvalent  serum  has  still  to  be  ascertained, 
but,  at  least,  it  may  be  said  that,  as  it  is  impossible  to  ascertain 
the  nature  of  the  infecting  strain  of  streptococcus  in  an  individual 
case,  or,  even  if  it  could  be  ascertained,  to  prepare  a  correspond- 
ing serum,  the  polyvalent  serum  increases  the  chance  of  success- 
fully combating  the  infection.  To  be  of  value,  however,  the 
serum  must  be  freshly  prepared,  and  a  sufficiently  large  dose 
must  be  administered. 

Various  toxic  symptoms  not  infrequently  follow  the  use  of  anti- 
streptococcic serum,  such  as  cutaneous  eruptions  and  joint  pains. 
These  symptoms  are  probably  mainly  due  to  the  introduction 
into  the  system  of  horse  serum.  They  are  transient,  and,  in 
comparison  with  the  condition  for  which  the  serum  is  used,  are 
of  no  importance. 

Other  remedial  measures  that  have  been  recommended  are 
unguentum  Crede  and  a  substance  known  as  nuclein.    Unguentum 

*  At'chiv  f.  Gyndk.,  1904,  vol.  xxiii.,  Heft  1. 
t  Lancet,  1904,  vol.  ii.,  p.  1828. 


PYEMIA  935 

Crede,  as  its  name  implies,  was  introduced  by  Crede,  and  con- 
tains fifteen  per  cent,  of  a  silver  salt  called  collargolum.  Cases 
in  which  apparent  benefit  have  followed  its  use  have  been 
recorded,  and,  as  it  is  a  simply  adopted  remedy,  it  may  be  tried 
without  prejudicing  the  effect  of  other  treatment.  From  fifteen 
to  forty-five  grains  should  be  rubbed  once  or  twice  daily  into 
the  skin  on  the  inner  aspect  of  the  thigh,  the  duration  of  the 
inunction  being  from  fifteen  to  twenty  minutes.  The  site  of 
inunction  should  be  then  covered  with  rubber  tissue.  Another 
method  of  introducing  the  silver  into  the  system  consists  in  the 
injection  of  soluble  collargolum,  dissolved  in  distilled  water,  under 
the  skin  or  into  a  vein.  A  half,  or  a  one  per  cent,  solution  is 
used,  and,  as  a  rule,  from  two  and  a  half  to  five  drachms  of  the 
former,  or  from  a  drachm  and  a  quarter  to  two  drachms  and  a 
half  of  the  latter  are  injected.  Nuclein  is  a  substance  obtained 
from  yeast,  and,  when  introduced  into  the  system,  is  said  to  cause 
an  artificial  leucocytosis,  and  thus  to  increase  the  natural  resistance 
to  bacterial  invasion.  It  can  be  given  hypodermically  or  by 
the  mouth. :::  In  the  former  case,  the  initial  dose  is  ten  minims 
twice  a  day,  and  this  amount  is  increased  by  five  minims  daily. 
In  the  latter  case,  from  half  a  drachm  to  a  drachm  is  given  twice 
daily.  Like  antistreptococcic  serum,  nuclein  sometimes  causes 
severe  pains  in  the  bones,  especially  in  the  tibia,  but  these  as  a 
rule  disappear  within  a  week. 

Pyemia. — The  condition  that  results,  when  the  infection  is 
carried  by  the  veins,  presents  many  of  the  features  of  lymphatic 
sepsis,  and  also  presents  others  that  are  distinctive.  '  Pyaemia 
may  be  defined  as  septicaemia  plus  thrombotic  and  embolic 
accidents  which  lead  to  distribution  of  infectious  material  to  all 
parts  of  the  body.'f 

Pyaemia  is  due  to  the  breaking-off  and  distribution  by  the  blood- 
stream of  fragments  of  infective  thrombi.  It  may  occur  whenever 
the  veins  of  the  uterus  or  pelvis  have  been  infected,  whether  the 
infection  was  due  to  primary  thrombosis  at  the  placental  site, 
or  to  a  phlebitis  spreading  to  the  veins  from  the  uterine  wall  or 
cellular  tissue.  The  fragments  of  clot  travel  in  the  blood-stream, 
and,  wherever  they  lodge,  new  foci  of  infection  originate,  resulting 
in  a  large  number  of  small  abscesses.  The  commonest  site  of 
these  secondary  abscesses  is  the  lungs,  but  they  frequently  are 
eventually  found  in  the  kidneys,  spleen,  and  liver,  and  may  occur 
anywhere  in  the  body. 

Septic  endocarditis  is  a  common  occurrence  in  pyaemia.  The 
left  side  of  the  heart,  particularly  the  mitral  valve,  is  the  part 
usually  affected,  though  right  endocarditis  may  result  from  the 
lodgment  of  an  infective  embolus  carried  direct  from  the  pelvis. 
A  copious  exudate  is  formed,  which,  being  swept  away,  leaves 

*  Hof  bauer,  Ccntvalb.  f.  Gyndk.,  1896,  vol.  xx.,  No.  17,  p.  441. 
t  Roswell  Park,  '  Treatise  on  Surgery,'  p.  104. 


936  PATHOLOGY  OF  THE  PUERPERIUM 

a  deep  ulcerating  surface,  on  which  an  exudate  again  forms. 
As  the  vegetations  thus  formed  are  swept  away  in  the  blood,  they 
may  be  carried  to  the  brain,  cerebral  membranes,  or  retina, 
causing  various  lesions  in  those  sites.  A  purulent  synovitis  of 
one  or  more  of  the  large  joints  is  not  uncommon  as  one  of  the 
metastatic  infections  of  pyaemia. 

In  addition  to  the  disseminated  lesions  just  described,  a  case 
of  pyaemia  presents  many  of  the  general  changes,  such  as  effusions 
and  extravasations,  as  well  as  changes  in  the  blood,  described 
as  occurring  in  septicaemia.  In  pyaemia,  however,  the  toxaemia 
is,  as  a  rule,  less  in  degree,  and  the  tissues  attacked  are  con- 
sequently able  to  make  a  better  resistance.  We  have,  therefore, 
in  this  case  a  disseminated,  and  in  septicaemia  a  diffuse,  infection. 

Symptoms. — The  symptoms  of  pyaemia  differ  from  those  of 
lymphatic  sepsis,  in  that  they  appear  at  a  later  date,  and  that 
they  are  essentially  of  a  remittent  type  instead  of  being  con- 
tinuous and  progressive.  The  actual  symptoms  of  the  pyaemic 
infection,  as  a  rule,  do  not  occur  until  after  the  eighth  day,  but, 
in  many  cases,  they  are  preceded  by  the  symptoms  of  a  local 
septic  infection.  The  first  symptom  is  usually  a  rigor,  followed 
by  a  sudden  rise  in  the  temperature  and  the  pulse-rate,  the  former 
reaching  from  1040  F.  to  1060  F.,  and  the  latter  from  no  to  130. 
In  a  few  hours,  the  temperature  falls  to  normal,  and  the  patient 
may  appear  to  be  as  well  as  she  was  prior  to  the  attack.  Another 
rigor,  however,  usually  follows,  with  a  more  marked  rise  of 
temperature,  and  this  is  succeeded  by  others  according  as  ad- 
ditional infected  emboli  break  away  from  the  uterine  circulation, 
and  are  carried  to  previously  healthy  tissues.  The  remaining 
symptoms  of  pyaemia  are  due  to  the  local  metastatic  infection 
that  occurs  in  the  tissues  to  which  the  infected  emboli  have  been 
carried.  It  has  often  been  noticed  that  these  emboli  tend  to 
follow  one  or  other  of  two  courses,  and  either  tend  to  pass 
into,  and  infect,  the  deeper  tissues  and  organs  of  the  body,  or  to 
lodge  more  superficially  in  the  skin  and  joints.  In  the  former 
class  of  case,  abscesses  may  form  in  the  lungs,  liver,  brain,  etc., 
or  a  septic  pneumonia  may  result.  In  the  latter  class,  abscesses 
may  form  in  the  subcutaneous  tissues  or  in  the  joints.  The 
gravity  and  persistence  of  the  symptoms  is  in  proportion  to  the 
virulence  of  the  infecting  organism.  In  severe  cases,  the  periods 
of  intermission  of  pyrexia  become  shorter,  and,  finally,  the  pyrexia 
becomes  persistent.  The  patient  then  passes  into  a  condition 
resembling  that  met  with  in  lymphatic  sepsis,  and  soon  succumbs. 

Diagnosis. — If  rigors  and  rise  of  temperature  occur  in  a  patient 
in  whom  the  genital  tract  is  known  to  be  infected  by  pyogenic 
organisms,  the  diagnosis  of  pyaemia  may  be  almost  definitely 
made.  If,  however,  the  lochia  have  not  been  examined,  it  may 
not  be  possible  to  make  a  certain  diagnosis  until  the  appearance 
of  metastatic  infections. 

Treatment. — The  treatment  of  pyaemia  must  be  turned  in  three 


TREATMENT  OF  PYJEMIA  937 

directions  : — The  strength  of  the  patient  must  be  maintained  ; 
the  centre,  from  which  the  septic  emboli  are  coming,  must,  if 
possible,  be  rendered  aseptic  ;  and  the  areas  of  metastatic  infec- 
tion must  be  treated.  With  the  object  of  maintaining  the  strength 
of  the  patient,  she  must  be  given  as  much  fluid  and  solid  nourish- 
ment as  she  can  digest.  If  iron  can  be  administered  without 
interfering  with  the  digestion  of  the  patient,  its  use  is  as  a  rule 
indicated,  either  alone  or  in  combination  with  strychnine.  The 
administration  of  alcohol  is  also  usually  necessary,  and  in  acute 
cases  must  be  pushed  as  far  as  the  patient  will  allow,  as  in  the 
case  of  lymphatic  infection.  The  centre  from  which  the  infected 
emboli  are  coming  is,  as  a  rule,  the  uterus,  and  the  treatment 
which  has  been  described  under  the  head  of  local  septic  infection 
must  be  carried  out.  Curetting  is,  however,  inadvisable,  as  its 
only  result  would  probably  be  to  dislodge  a  fresh  shower  of 
infected  emboli.  The  use  of  ergot  is  advisable,  as,  by  promoting 
uterine  contractions,  it  may  tend  to  check  the  extension  of  infec- 
tion. If  metastatic  abscesses  form  in  joints,  they  must  be  opened 
and  drained  as  soon  as  possible,  in  order  to  save  the  joint  from 
destruction.  If  they  form  beneath  the  skin  or  muscles,  they 
may  be  allowed  to  point  before  they  are  opened.  Purulent 
effusions  into  any  of  the  serous  cavities  must  be  drained,  and 
septic  pneumonia  and  endo-  or  peri-carditis  treated  in  the  usual 
manner.  If  the  infection  is  due  to  streptococci,  anti-streptococcic 
serum  may  be  tried,  as  its  use  has  occasionally  been  attended 
with  favourable  results.  Saline  infusions  are  also  of  use,  if  the 
patient  is  in  a  toxaemic  condition. 


CHAPTER  II 
DISEASES  ASSOCIATED  WITH  THE  PUERPERIUM 

Crural  Phlebo-thrombosis  —  The  Insanities  of  Reproduction  —  Mastitis — 
Pulmonary  Embolus — Sub-involution  of  the  Uterus — Super-involution 
of  the  Uterus. 

CRURAL  PHLEBO-THROMBOSIS 

Thrombosis  of  the  veins  of  the  leg  is  by  no  means  an  uncommon 
occurrence  after  delivery,  and  may  be  due  to  several  different 
causes.  In  the  first  place,  it  may  be  a  simple  thrombosis  due  to 
the  slowness  of  the  circulation  of  the  blood  through  relaxed  veins. 
The  occurrence  of  such  cases  is  favoured  by  anything  which 
weakens  the  heart's  action,  and  by  the  presence  of  varicose  veins. 
In  some  cases  the  clot  may  form  in  the  femoral  vein,  in  other  cases 
in  the  veins  of  the  lower  leg.  The  nearer  the  heart  the  thrombosis 
forms,  the  greater  will  be  the  disturbance  of  the  venous  system  of 
the  affected  leg,  and  the  more  marked  the  symptoms.  In  the 
second  place,  the  thrombosis  may  be  due  to  an  inflammation  of 
the  inner  coat  of  the  vein.  In  the  majority  of  cases,  this  phlebitis 
is  the  result  of  direct  extension  of  infection  along  the  walls  of 
the  vein  from  previously  infected  uterine  sinuses.  In  a  small 
proportion  of  cases,  however,  the  phlebitis  is  localised  and  is 
apparently  not  continuous  with  an  infection  in  the  uterine  sinuses 
or  pelvic  veins.  The  aetiology  of  such  cases  is  extremely  obscure, 
but,  it  is  probable  that  they  are  due  to  the  irritation  of  the  walls 
of  the  vein  by  the  toxins  of  infecting  organisms.  In  a  certain 
proportion  of  cases,  the  lymph  channels  are  obstructed  as  well 
as  the  veins,  or  perhaps  may  be  alone  obstructed.  Such  an 
obstruction  may  arise  from  the  extension  of  a  lymphangitis  from 
the  pelvic  lymphatics,  or  may  be  perhaps  due  to  the  compression 
of  the  main  pelvic  lymph  channels  by  already  thrombosed  pelvic 
veins.  Cases  of  lymphatic  obstruction  are  probably  always  of 
infective  origin,  and  are  now  not  so  commonly  seen  as  they  were 
formerly. 

Varieties. — From  the  foregoing  we  see  that  phlebo-thrombosis 
of  the  leg  occurs  in  two  distinct  varieties  : — 

938 


CRURAL  PHLEBO-THROMBOSIS  939 

(1)  A  primary  and  simple  form,  the  result  of  slowness  of  the 
circulation  through  the  veins. 

(2)  A  secondary  and  septic  form,  the  result  of  the  extension  of 
infection  from  the  uterus  along  the  walls  of  the  vein,  or  of  the 
irritation  of  the  inner  coat  by  toxic  substances  circulating  in  the 
blood.  In  this  form,  there  may  be  an  accompanying  obstruction 
to  the  lymph  channels. 

Symptoms.  —  The  symptoms  common  to  all  forms  of  venous 
obstruction  are  pain  and  swelling  of  the  legs,  in  proportion  to  the 
size  and  situation  of  the  obstructed  vessel.  If  the  femoral  vein 
is  blocked,  the  swelling  of  the  leg  is  very  considerable,  while  if 
only  a  few  small  veins  in  the  calf  are  obstructed  there  is  only  a 
little  oedema  in  the  neighbourhood  of  the  ankle.  The  thrombosed 
veins,  if  superficial,  can  be  felt  as  knotty  cords  beneath  the 
skin.  In  the  secondary  septic  form,  pain  as  a  rule  precedes  the 
swelling.  It  may  start  in  the  groin  and  then  extend  down  the 
leg  along  the  course  of  the  infected  veins,  or  it  may  be  referred 
to  a  particular  place  on  the  thigh  or  calf.  The  leg  is  extremely 
tender  to  the  touch,  particularly  over  the  infected  vein.  In  some 
cases,  localised  areas  of  inflammation  may  appear  along  the  course 
of  the  vein  and  subsequently  break  down  into  abscesses,  or  the 
position  of  the  affected  veins  may  be  indicated  by  lines  of  slight 
inflammation,  running  down  the  thigh.  In  the  condition  known 
as  phlegmasia  alba  dolens,  or  white  leg,  in  which  the  lymphatics  are 
affected  and  probably  the  veins  also,  the  leg  may  become  of  an 
enormous  size,  the  skin  is  stretched  and  is  white  and  glistening, 
and  the  pain  is  intense.  If  the  engorgement  is  due  to  the  obstruc- 
tion of  the  lymphatics  alone,  the  tissues  of  the  leg  have  a  peculiar 
brawny  feel  and  will  not  pit  upon  pressure.  If,  on  the  other 
hand,  there  is  also  venous  obstruction,  the  tissues  are  cedematous 
and  pit  on  pressure. 

In  the  primary  form,  there  is  little  or  no  constitutional  disturb- 
ance other  than  that  due  to  the  weakness  of  the  patient.  In  the 
septic  form,  on  the  other  hand,  there  are  usually  all  the  evidences 
of  septic  infection  of  a  varying  intensity.  In  some  cases  the 
symptoms  may  point  to  the  presence  of  a  septic  endometritis  or 
parametritis,  in  other  cases  to  the  existence  of  a  pyaemic  con- 
dition, while  in  a  few  cases  there  may  be  no  definite  signs  of 
infection  until  the  presence  of  thrombosis  shows  that  it  must  have 
occurred. 

Treatment. — The  three  main  points  in  the  treatment  of  each 
form  of  thrombosis  are  rest  in  bed  with  the  leg  elevated,  regulation 
of  the  bowels,  and  the  administration  of  abundance  of  easily 
digested  nourishment.  Iron  may  also  be  given  and  strychnine  if 
the  heart  is  weak.  The  leg  must  be  carefully  protected,  particu- 
larly in  phlegmasia,  from  the  pressure  of  the  clothes,  as  in  some 
cases  even  the  slightest  touch  aggravates  the  pain.  Some  relief 
will  be  given  by  wrapping  the  leg  in  cotton-wool,  and  keeping  the 
latter  moistened  with  evaporating  lead  lotion.     In  septic  forms, 


94°  PATHOLOGY  OF  THE  PUERPERIUM 

where  there  are  localised  areas  of  inflammation,  the  use  of  hot 
antiseptic  compresses  is  preferable.  In  all  cases,  sudden  move- 
ments must  be  avoided,  and  in  no  case  may  friction  of  the  leg 
be  employed  on  account  Of  the  danger  of  detaching  a  clot.  If 
abscesses  form,  they  must  be  opened.  Constitutional  symptoms 
due  to  the  infection  must  be  treated  as  has  been  already  described. 
The  patient  must  not  be  allowed  to  leave  her  bed  for  at  least 
ten  days  after  fever,  pain,  and  swelling  have  disappeared.  It 
may,  however,  be  expected  that,  as  soon  as  she  commences  to 
walk  on  the  leg,  some  pain  and  swelling  will  return  owing  to  the 
uninjured  veins  not  being  as  yet  large  enough  to  carry  on  the 
circulation  when  the  woman  is  in  the  erect  position.  Indeed,  it 
is  probable  that  according  to  the  size  of  the  obstructed  vessels 
it  will  be  several  months  or  a  year  before  she  is  free  from  all 
pain,  and,  for  many  years  after,  the  pain  and  swelling  will  return 
to  a  slight  extent  after  prolonged  walking  or  standing. 


THE  INSANITIES  OF  REPRODUCTION 

The  strain  thrown  by  pregnancy  and  parturition  on  the 
maternal  organism  is,  as  we  have  already  mentioned,  a  frequent 
source  of  minor  psychical  abnormalities,  and,  consequently,  it  is 
not  strange  that,  in  those  whose  nervous  system  is  weak  or  hyper- 
irritable,  it  may  lead  to  complete  mental  breakdown.  Insanity  of 
such  an  origin  may  occur  during  pregnancy,  the  puerperium,  or 
lactation  ;  and,  since  the  type  met  with  at  each  of  these  periods 
differs  to  some  extent,  and  has  its  own  characteristics,  it  is 
convenient  to  make  these  periods  the  basis  of  a  classification, 
the  puerperium  being  assumed  to  commence  with  labour  and  to 
end  six  weeks  later.  Roughly  speaking,  insanity  occurs  at  least 
once  in  every  three  hundred  births,  and  composes  from  seven  to 
ten  per  cent,  of  all  cases  of  mental  disease  in  females. 

The  Insanity  of  Pregnancy. 

Insanity  during  pregnancy  is  a  rare  occurrence,  and  only 
accounts  for  one  to  two  per  cent,  of  all  female  cases  in  asylums, 
though  mild  cases  which  do  not  require  special  treatment  are 
more  common.  A  neurotic  diathesis  is  present  in  a  large  pro- 
portion of  instances,  while  previous  nervous  or  mental  illness, 
organic  disease,  alcoholism,  and  moral  factors  such  as  illegitimacy 
and  desertion  also  constitute  predisposing  influences.  Insanity 
is  most  prone  to  occur  during  first  pregnancies,  especially  if 
these  occur  late  in  life  or  in  unmarried  women,  and,  if  the 
pregnancy  is  associated  with  severe  bodily  strain,  there  is  a 
greater  likelihood  of  the  development  of  mental  trouble.  The 
direct  causes  are  partly  nervous  and  partly  hsemic  in  origin. 
The  nervous  causes  include  mental  and  bodily  discomfort   and 


THE  INSANITY  OF  PREGNANCY  941 

other  sources  of  reflex  irritation,  and  the  increased  irritability  of 
the  nerve  centres ;  while  it  has  been  suggested  that  the  altered 
condition  of  the  blood  may  consist  in  a  deficiency  of  phosphoretted 
bodies  of  the  lecithin  group,  resulting  from  the  demands  made  by 
the  growing  nervous  system  of  the  foetus.* 

Symptoms  and  Course. — -The  onset  of  insanity  is  usually  gradual. 
If  the  attack  begins  before  the  fourth  month,  it  is  milder  in 
character  than  when  it  starts  later,  and  presents  symptoms  more 
like  an  exaggeration  of  the  longings  and  fears  common  at  this 
period.  In  such  cases,  the  attack  as  a  rule  begins  at  the  time 
when  other  disturbances,  such  as  neuralgia  and  morning  sickness, 
commonly  set  in.  The  patient  begins  to  show  a  nervous  timidity 
and  suspicion,  with  dread  of  impending  misfortune.  She  is 
apathetic  and  depressed,  given  to  self-accusation,  distrustful  of 
her  husband  and  relatives,  and  may  show  dislike  to  her  children 
and  even  try  to  kill  them,  while  suicide  is  always  to  be  feared. 
Her  depression  may  be  acute,  though  this  is  unusual,  and,  in 
exhausted  patients,  the  attack  may  assume  a  maniacal  form. 

Insanity  commencing  in  the  later  months  is  more  common  and 
more  severe,  and  is  usually  melancholic  in  type.  It  commences 
like  the  earlier  attacks,  but  rapidly  passes  into  acute  depres- 
sion, accompanied  by  sleeplessness,  incoherence,  delusions  and 
hallucinations  which  are  of  an  unpleasant  and  often  terrifying 
nature,  and  which  frequently  take  the  form  of  hypochondriacal 
ideas  or  suspicions  of  poisoning.  There  is  a  strong  suicidal 
tendency,  and  the  patient  is  often  violent  and  even  homicidal. 
A  considerable  number  of  cases  are  maniacal  in  character,  the 
mania  being  of  the  ordinary  type,  or  hysterical,  or  delirious, 
but  even  then  the  delusions  are  frequently  terrifying.  During 
convalescence,  the  patients  often  pass  through  a  stage  of  mis- 
chievousness  and  viciousness.  In  unfavourable  cases,  the  pro- 
gress to  dementia  is  likely  to  be  rapid.  Chronic  delusional 
insanity,  general  paralysis,  and  the  group  of  symptoms  known 
as  katatonia,  have  also  been  known  to  start  at  this  period.  The 
last  named  is  characterised  by  a  stage  of  melancholia  followed 
by  one  of  alternating  excitement  and  stupor,  with  delusions  and 
certain  peculiar  psycho-motor  disturbances,  and  ending  in  a 
dementia  marked  by  absence  of  judgment  and  emotion,  percep- 
tion and  memory  persisting  for  a  time. 

Treatment. — Freedom  from  worry,  fresh  air  and  moderate 
exercise,  good  food,  regulation  of  the  bowels,  and  sleep  are  the 
essentials  of  treatment  at  all  stages,  and  the  patient  should  be 
separated  from  her  husband  and  relatives.  Constant  watching  to 
guard  against  suicide  is  necessary  throughout.  In  the  late  cases, 
it  is  usually  necessary  to  send  the  patient  to  an  asylum,  unless 
careful  nursing  and  frequent  medical  supervision  can  be  provided 
at  home.  The  induction  of  abortion  or  premature  labour  is  risky 
and  rarely  justifiable.     The  use  of  opium  should  be  avoided,  but 

*  F.  W.  Mott,  Trans.  Obstet.  Soc.  Lond.,  vol.  xlv.,  p.  31. 


942  PATHOLOGY  OF  THE  PUERPERIUM 

small  doses  of  chloral  and  bromides  may  be  given  if  necessary. 
Simple  tonics,  and  especially  the  glycero-phosphates,  free  phos- 
phorus, or  lecithin  (from  three  to  five  grains  in  the  day)  are 
indicated,  but,  for  the  sake  of  the  child,  as  few  drugs  as  possible 
should  be  used. 

Prognosis. — From  a  half  to  two-thirds  of  all  patients  recover,  and 
but  few  die  as  a  direct  consequence  of  the  attack.  In  the  early 
cases,  recovery  often  occurs  at  the  period  of  quickening,  and 
usually  takes  place  before  the  end  of  pregnancy.  In  the  late 
cases,  it  may  occur  soon  after  confinement,  but  many  cases  pass 
into  puerperal  insanity.  Most  recoveries  are  complete  within  six 
months.  The  risk  of  recurrence  in  subsequent  pregnancies  is 
great,  and  the  outlook  for  the  mental  condition  of  the  infant  is 
gloomy.  In  general  paralysis,  the  downward  course  becomes  less 
rapid  after  delivery. 

The  Insanity  of  the  Puerperium. 

Puerperal  insanity  constitutes  about  five  per  cent,  of  all  mental 
disease  in  women,  and  occurs  about  once  in  every  400  to  500  con- 
finements. Neurotic  heredity  is  frequent,  and  previous  nervous 
or  mental  illnesses,  worry,  ill-health  during  pregnancy,  organic 
disease,  and  alcoholism,  also  predispose  to  its  occurrence.  Other 
causes  are  to  be  found  in  first  confinements,  especially  when 
late  in  life,  illegitimacy,  prolonged  labour,  the  excessive  use  of 
anaesthetics,  post-partum  haemorrhage,  acute  febrile  diseases,  and 
above  all  sepsis.  The  immediate  causes  may  be  the  ordinary 
stress  of  labour,  the  reflex  changes  and  awakening  of  maternal 
instincts  which  accompany  it,  and  the  absorption  of  toxins  and 
of  the  effete  products  of  involution  ;  moreover,  sudden  grief  or 
nervous  shock  during  or  shortly  after  parturition  often  starts  an 
attack.  It  is  improbable  that  all  cases  are  toxic,  though  the 
form  of  the  disease  is  characteristic  of  toxic  insanity. 

Symptoms  and  Course.  —  Uncontrollable  maniacal  excitement 
sometimes  comes  on  suddenly  during  labour,  and  usually  ceases 
as  suddenly  after  delivery.  There  is  also  a  rare  ephemeral  mania 
or  delirium,  which  begins  during  the  first  three  days  of  the  puer- 
perium with  rapid  pulse,  tremulous  tongue,  tender  breasts,  and 
constipation,  and  passes  off  as  lactation  is  established  and  the  free 
action  of  the  bowels  is  obtained. 

Ordinary  puerperal  insanity  appears,  as  a  rule,  a  little  later 
than  this,  about  half  the  cases  occurring  within  the  first  week. 
Its  onset  is  sudden,  and,  if  the  insanity  is  of  septic  origin,  is 
accompanied  by  a  rigor.  The  attack  usually  assumes  the  form 
of  a  very  acute  mania,  and  this  is  the  more  acute  the  earlier 
the  attack  commences.  The  patient  becomes  dull  and  depressed, 
loses  interest  in  her  child  and  surroundings,  and  suffers  from 
vague  groundless  fears,  headache,  insomnia,  and  loss  of  appetite. 
From  this  state  she  passes  into  one  of  feverish  restlessness,  and 


THE  INSANITY  OF  THE  PUERPERIUM  943 

becomes  discontented,  suspicious,  and  exacting,  and  shows  dislike 
to  her  husband,  the  attendants,  and  her  child,  whom  she  may  try 
to  kill.  Her  face  becomes  haggard,  her  eyes  bright,  her  lips  and 
tongue  dry,  her  pulse  weak,  and  her  temperature  often  rises  above 
ioo°  F.  In  septic  cases,  the  uterus  may  be  tender  and  the  lochia 
fcetid,  or,  when  the  infection  is  most  acute,  all  local  symptoms 
may  be  absent.  The  patient  mistakes  her  identity  and  that  of 
those  about  her,  is  generally  confused,  and  has  delusions  of 
suspicion,  especially  of  poisoning,  and  hallucinations,  which  are 
usually  auditory.  She  refuses  her  food,  and  may  be  erotic  and 
indecent  in  word  and  gesture,  and  at  the  same  time  may  show 
religious  exaltation.  Finally,  especially  in  septic  cases,  she  may 
pass  into  a  state  of  uncontrollable  and  restless  violence,  in  which 
she  is  sleepless,  incoherent,  and  dirty,  refuses  all  food,  and  looks 
sallow  and  anaemic.  Her  tongue  is  furred  and  dry,  sordes 
accumulate  on  the  lips  and  teeth,  her  pulse  is  weak,  and 
sometimes  her  temperature  is  high.  If  the  blood  is  examined, 
there  is  found  to  be  an  actual  diminution  in  the  amount  of 
haemoglobin.  Many  cases  are  suicidal.  If  the  case  comes  early 
under  treatment,  some  improvement  may  be  seen  in  a  week,  and 
complete  recovery  may  result,  though  prior  to  the  establishment 
of  convalescence  relapses  are  not  uncommon.  In  many  cases, 
however,  there  may  be  no  improvement  for  six  to  eight  weeks, 
and  there  is  often  a  stage  of  apathy  or  stupor,  or  of  discontent, 
which  may  become  chronic.  Recovery  is  usually  coincident  with 
the  re-establishment  of  menstruation. 

In  some  cases,  the  excitement  is  of  a  melancholic  character, 
with  terrifying  delusions  and  hallucinations,  resistiveness,  and  a 
strong  suicidal  tendency,  but,  as  a  rule,  the  melancholic  cases,  of 
which  there  are  a  considerable  number,  are  of  a  milder  type  than 
the  maniacal.  They  usually  commence  late  and  run  a  tedious 
and  prolonged  course.  Delusional  insanity  and  general  paralysis 
seldom  develop  after  child-birth.  Katatonia,  on  the  other  hand, 
is  common,  according  to  Kraepelin.* 

Treatment. — As  preventive  measures,  the  health  of  patients 
subject  to  mental  breakdown  should  receive  special  care  during 
pregnancy,  and  every  precaution  should  be  taken  to  ensure  an 
easy  and  short  labour.  It  is  advisable  to  deliver  the  fcetus 
instrumentally,  if  labour  is  prolonged,  in  order  to  avoid  the 
occurrence  of  exhaustion ;  anaesthetics  should  be  administered 
only  if  necessary.  Afterwards,  the  patient  must  be  kept  abso- 
lutely quiet  for  some  days,  and  sleep  and  proper  action  of  the 
bowels  secured. 

On  the  first  appearance  of  suspicious  symptoms,  the  infant 
must  be  instantly  removed,  and  the  patient  kept  perfectly  quiet, 
and  under  constant  supervision  for  fear  of  suicide.  Attention 
must  be  paid  to  the  breasts,  and,  if  there  is  evidence  of  septic 
infection,  it  must  be  treated  as  its  form  necessitates.     The  bowels 

*   'Lectures  on  Clinical  Psychiatry,'  ed.  Johnstone,  pp.  38,  129  et  seq. 


944  PATHOLOGY  OF  THE  PUERPERIUM 

should  be  freely  opened  by  means  of  saline  purgatives.  The 
attack  may  sometimes  be  cut  short  at  the  outset  by  full  doses  of 
chloral  or  paraldehyde  by  the  mouth  or  the  rectum,  so  as  to 
secure  deep  sleep.  If  these  measures  fail,  the  patient  should  be 
sent  to  an  asylum  without  delay,  unless  skilled  nursing  and 
medical  attendance  is  available  and  the  patient's  residence  is 
suitably  situated.  Separation  from  the  husband  and  children  is 
in  all  cases  essential,  and,  if  there  is  no  improvement  within  six 
weeks,  the  patient  should  be  sent  to  an  asylum.  Everything 
depends  on  efficient  and  early  treatment,  the  most  important 
part  of  which  is  feeding,  and  large  amounts  of  liquid  nourish- 
ment— eggs,  milk,  beef-tea,  strong  soups,  plasmon,  and  the  like, 
with  cod-liver  oil  or  malt  extract — must  be  given  every  few 
hours,  both  night  and  day,  if  necessary  by  the  nasal  or  mouth 
tube.  Malt  liquors  are  particularly  useful,  and  may  be  taken 
in  large  quantities.  As  purgatives,  repeated  and  full  doses  of 
calomel,  jalap,  or  even  croton  oil  are  well  borne,  and  should  be 
given  if  necessary.  In  order  to  induce  sleep,  paraldehyde,  chloral 
with  bromide,  or  sulphonal  if  there  is  much  excitement,  may  be 
tried,  but  the  use  of  opium  or  hyoscine  must  be  avoided.  To 
relieve  restlessness,  sponging,  the  wet  pack,  and  prolonged  warm 
baths  are  useful.  If  the  temperature  is  high,  from  ten  to  fifteen 
grains  of  quinine  should  be  administered  every  few  hours,  and  in 
cases  of  septic  infection  due  to  the  streptococcus,  antistreptococcic 
serum  may  be  tried.  When  the  stage  of  excitement  is  passing 
off,  the  patient  should  spend  longer  each  day  in  the  open  air,  and, 
in  the  later  stages,  the  use  of  Easton's  syrup  or  a  similar  tonic 
and  of  iron  is  indicated.  Electric  baths  and  the  administration 
of  thyroid  extract  may  be  tried  in  the  case  of  depressed  and 
stuporose  patients,  but  these  often  make  good  recoveries  if 
allowed  to  return  to  their  home  under  supervision.  As  a  rule, 
marital  relations  should  not  be  resumed  for  some  months. 

Prognosis. — Seventy-five  to  eighty  per  cent,  of  patients  recover, 
and  a  few  die  of  exhaustion  or  sepsis.  About  half  the  recoveries 
are  complete  within  four  months,  and  about  ninety  per  cent,  within 
nine  months,  but  a  cure  may  take  place  even  after  several  years. 
Acute  and  early  cases  get  well  quickly.  Apathetic  and  depressed 
cases  and  those  beginning  late  are  tedious.  Recurrence  in  sub- 
sequent confinements  is  probable,  but  not  invariable.  After 
several  recurrences  permanent  dementia  is  to  be  expected,  while 
there  is  also  a  tendency  to  mental  breakdown  at  the  climacteric. 
Albuminuria  is  an  unpromising  sign,  and  so  is  a  return  of  men- 
struation when  unaccompanied  by  mental  improvement. 

The  Insanity  of  Lactation. 

The  insanity  of  lactation  forms  from  three  to  four  per  cent,  of 
all  cases  of  mental  disease  in  females.  It  is  essentially  an  insanity 
of  malnutrition  and  exhaustion,  and  chiefly  occurs  in  multiparas 


THE  INSANITY  OF  LACTATION  945 

of  the  poorer  classes  with  a  neurotic  family  history.  Previous 
attacks  of  insanity,  especially  of  puerperal  insanity,  frequent 
pregnancies,  prolonged  and  excessive  suckling,  hard  work  and 
insufficient  nourishment,  and  abnormalities  of  parturition  or  of 
uterine  involution  are  also  predisposing  causes,  while  weaning  is 
said  to  be  sometimes  the  immediate  cause.  The  causation  of  the 
earlier  cases  is  similar  to  that  of  puerperal  insanity,  with  the  addi- 
tion of  exhaustion ;  of  the  later  cases,  exhaustion  is  the  sole  cause. 

Symptoms  and  Course. — The  earlier  cases — namely,  those  com- 
mencing within  three  months  of  labour — are  usually  maniacal, 
start  suddenly,  and,  in  fact,  resemble  mild  puerperal  cases. 
In  the  later  and  typical  cases,  which  are  of  a  depressed  type, 
the  onset  is  usually  gradual.  The  first  symptoms  are  those  of 
severe  anaemia,  accompanied  by  lassitude,  restless  irritability,  fret- 
fulness,  suspicion,  and  sleeplessness.  The  patient  then  develops 
delusions  of  impending  misfortune,  of  her  own  wickedness  and 
her  husband's  infidelity,  of  poison  in  her  food,  and  the  like ; 
and  hallucinations,  usually  of  hearing,  and  often  of  a  terrifying 
character,  are  very  common,  as  are  homicidal  and  suicidal  im- 
pulses. The  patient  is  sometimes  worse  towards  evening.  In 
some  cases,  the  condition  changes  to  one  of  stupor  with  refusal 
of  food  ;  in  others,  especially  where  there  is  great  exhaustion,  a 
period  of  depression  is  followed  by  acute  mania,  accompanied 
by  confusion,  incoherence,  violence,  and  destructiveness ;  but, 
in  no  form  are  the  symptoms  so  acute  as  in  puerperal  insanity. 
Amenorrhcea  is  the  rule,  and,  if  the  menses  have  returned,  they 
are  probably  accompanied  by  excitement  and  exhaustion.  Under 
proper  treatment,  all  the  symptoms  gradually  subside. 

Treatment. — The  patient  should  always  be  sent  away  from 
home,  but  not  necessarily  to  an  asylum,  save  in  the  early  and 
acute  cases,  and  especially  in  the  maniacal  cases.  Good  nursing 
and  constant  watching  are  always  necessary.  The  baby  must  be 
weaned  at  once,  and  the  breasts  attended  to.  The  bowels  must 
be  kept  open  with  laxatives  combined  with  iron,  such  as  aloes 
and  iron  pill,  and  sulphates  of  iron  and  magnesium.  Change, 
rest,  fresh  air,  a  generous  diet  which  at  first  may  be  peptonised, 
stimulants  if  required,  baths  and  cold  douches  to  the  spine, 
moderate  exercise  as  recovery  progresses,  and  tonics  such  as 
quinine,  iron,  and  arsenic,  constitute  the  treatment.  Sedatives 
are  to  be  avoided  as  far  as  possible,  and  sleep  secured  by  fresh 
air,  exercise,  baths,  and  night- feeding.  The  use  of  paraldehyde, 
bromides,  or  sulphonal,  may  sometimes  be  necessary,  and  in 
cases  of  marked  depression,  especially  if  accompanied  by  agitation, 
opium  may  give  relief. 

Prognosis. — Over  seventy  per  cent,  of  cases  recover,  and  the 
death-rate  is  very  small.  The  average  duration  is  about  nine 
months,  but  most  of  the  recoveries  will  be  complete  within  five 
or  six  months,  and  nearly  all  within  eighteen  months.  Relapses 
are  uncommon. 

60 


946  PATHOLOGY  OF  THE  PUERPERIUM 


MASTITIS 

Mastitis,  or  inflammation  of  the  breast,  is  of  relatively  common 
occurrence  during  the  puerperium  and  during  lactation.  It-  is 
a  distinctly  preventable  affection,  as  it  results  from  the  entrance 
of  pyogenic  bacteria  into  the  breast,  but,  in  some  cases,  it  is 
difficult  to  trace  the  source  of  the  infection.  The  entrance  of 
the  pyogenic  bacteria  is  the  exciting  cause,  and  the  flagging  of 
milk  in  the  breast,  or  general  debility  of  the  patient  are  the  pre- 
disposing causes  common  to  all  forms  of  mastitis. 

Varieties. — Two  forms  of  mastitis  occur — parenchymatous  or 
glandular,  mastitis,  and  interstitial  mastitis.  Parenchymatous 
mastitis  is  the  term  applied  to  the  inflammation  of  the  glandular 
structures  of  the  breast  as  distinct  from  the  inter-glandular  con- 
nective tissue.  Interstitial  mastitis  is  the  term  applied  to  in- 
flammation of  the  inter-glandular  connective  tissue.  It  is  probable 
that  in  all  severe  cases  of  mastitis  the  two  varieties  co-exist,  but, 
in  all  cases  at  the  commencement  of  the  attack,  and  in  some  cases 
at  all  times,  it  is  possible  to  distinguish  between  them.  We  shall, 
therefore,  discuss  them  separately. 

Parenchymatous  Mastitis. — Parenchymatous  mastitis,  in 
which  the  glandular  portion  of  the  breast  is  affected,  is  the 
less  severe  and  the  more  common  of  the  two  varieties. 

JEtiology. — The  cause  of  parenchymatous  mastitis  is  the  entrance 
of  pyogenic  bacteria  through  the  milk-ducts  of  the  nipple.  As 
a  rule,  one  or  more  ducts  are  affected,  the  others  remaining 
healthy.  The  infection  extends  backwards  through  the  infected 
ducts  into  the  lobules  which  they  drain.  If  the  case  is  treated  in 
time,  as  a  rule  the  infection  can  be  prevented  from  spreading 
further,  but  in  some  cases  it  may  pass  into  the  interstitial  tissue. 
Anything  which  predisposes  to  the  decomposition  of  milk  on  the 
nipple,  or  on  the  patient's  clothes  where  they  are  in  contact  with 
the  nipple,  predisposes  to  the  occurrence  of  mastitis,  as  the 
remains  of  milk  furnish  a  nidus  in  which  bacteria  can  collect,  and 
from  which  they  can  pass  into  the  ducts.  Similarly,  if  the  breast 
becomes  '  overstocked,'  so  that  the  milk  droplets  lie  for  too  long 
in  the  lactiferous  ducts,  a  suitable  nidus  is  provided  inside  the 
breast  for  the  development  of  the  bacteria  which  have  gained 
entrance. 

Symptoms. — The  first  symptoms  of  parenchymatous  mastitis 
are  a  sense  of  fulness,  pain,  and  heat  in  the  breast.  The  tempera- 
ture of  the  patient  usually  rises  to  ioo°  F.,  or  perhaps  a  little 
higher.  The  tongue  is  often  furred,  and  the  bowels  confined. 
The  next  day,  a  triangular  patch  of  inflammation  appears  on 
the  affected  breast.  This  triangle  corresponds  to  the  area  drained 
by  the  infected  duct,  its  base  is  situated  at  the  periphery  of  the 
breast,  its  apex  at  the  nipple,  and  its  outline  is  clearly  defined. 


INTERSTITIAL  MASTITIS  947 

In  addition  to  its  inflamed  appearance,  the  area  is  firmer  than 
the  rest  of  the  breast  and  extremely  tender.  If  more  than  one 
duct  is  affected,  other  similar  areas  will  also  be  present.  The 
temperature  may  reach  1020  F.,  and  the  pulse  may  attain  a  rate 
of  100  to  no.  The  patient  complains  of  considerable  local  pain 
and  of  general  malaise.  She  may  also  have  had  a  slight  attack 
of  shivering,  but  we  should  be  inclined  to  regard  such  an  occur- 
rence as  indicative  of  the  passage  of  the  infection  beyond  the 
ducts  into  the  interstitial  tissue. 

Interstitial  Mastitis. — Interstitial  mastitis  is  a  more  serious 
condition  than  is  the  variety  we  have  just  described,  inasmuch  as 
it  not  uncommonly  ends  in  the  formation  of  an  abscess. 

Aetiology. — Interstitial  mastitis  may  be  the  result  of  the  exten- 
sion of  a  parenchymatous  mastitis  from  the  milk  ducts  outwards, 
or  it  may  result  from  primary  infection  of  the  interstitial  tissue. 
In  such  cases,  the  infecting  bacteria  usually  gain  entrance  through 
cracks  in  the  skin  on  or  round  the  base  of  the  nipple. 

Symptoms. — The  initial  symptoms  of  interstitial  mastitis  are 
similar  to  those  of  parenchymatous  mastitis,  but  usually  tend  to 
become  more  marked.  A  patch  of  inflammation  appears  over 
the  infected  area,  and  differs  in  appearance  from  the  area  of 
inflammation  present  in  parenchymatous  mastitis  as  it  is  irregular 
in  shape  and  ill-defined.  On  palpation,  the  infected  area  is  found 
to  be  firmer  than  the  remainder  of  the  breast,  and  to  be  extremely 
tender,  and,  if  pus  has  formed,  the  covering  skin  is  oedematous, 
and  pits  on  pressure.  In  such  cases,  the  temperature  of  the 
patient  may  rise  to  1030  F.  to  1040  F.,  and  the  pulse  become  pro- 
portionately rapid.  The  patient  both  looks  and  feels  very  ill,  and 
occasional  rigors  may  occur. 

Treatment. — The  prophylactic  treatment  of  mastitis  consists  in 
preventing  the  occurrence  of  cracks  or  abrasions  of  the  delicate 
epithelium  of  the  nipple,  in  the  prevention  of  overstocking  of  the 
breast,  in  keeping  the  nipple  perfectly  clean,  and  in  taking  care 
that  any  necessary  manipulations  on  the  part  of  the  nurse  or  the 
woman  herself  are  always  performed  with  clean  fingers.  If  proper 
attention  has  been  paid  to  the  hardening  of  the  skin  of  the  nipple 
during  the  end  of  pregnancy,  cracks  are  unlikely  to  occur.  When 
the  woman  has  commenced  to  nurse,  a  little  aseptic  lanoline  or 
hazeline  cream  maybe  rubbed  on  the  nipples  once  or  twice  a  day, 
with  the  object  of  keeping  the  skin  soft  and  elastic.  If  a  crack 
occurs,  it  should  be  healed  as  quickly  as  possible  and  to  this  end 
may  be  touched  once  or  twice  very  lightly  with  nitrate  of  silver, 
or  painted  a  few  times  a  day  with  compound  tincture  of  benzoin. 
If  the  nipple  is  very  tender,  the  baby  had  better  nurse  at  first 
through  a  nipple-shield.  Overstocking  is  prevented  by  regu- 
lating the  amount  of  fluid  the  patient  drinks,  and  by  drawing 
off  a  small  quantity  of  milk  according  as  is  required.  Also,  if 
the  breast   is  heavy  and  tends  to  become  pendulous,  it  should 

60 — 2 


948  PATHOLOGY  OF  THE  PUERPERIUM 

be  supported  by  means  of  a  handkerchief  or  bandage  round  the 
chest. 

The  treatment  of  parenchymatous  mastitis,  or  of  interstitial 
mastitis  in  an  early  stage,  is  directed  to  preventing  an  extension 
of  the  infection.  Nursing  should  be  stopped,  at  any  rate  tem- 
porarily, both  in  the  interests  of  the  mother  and  the  infant.  If  the 
breast  is  overdistended,  it  must  be  emptied  with  a  breast  pump. 
A  free  purgative  should  be  administered,  and  the  subsequent 
regulation  of  the  bowels  attended  to.  The  breast  should  be 
covered  with  cotton-wool  and  bandaged  as  firmly  to  the  chest 
wall  as  is  possible  without  causing  pain.  In  a  considerable 
proportion  of  cases,  the  symptoms  will  subside,  and  as  soon  as 
all  trace  of  inflammation  has  passed  away,  and  the  temperature 
has  become  normal,  the  woman  may  be  again  allowed  to  nurse. 
Even  if  the  milk  has  temporarily  diminished  in  quantity,  it  will 
in  most  cases  again  return.  If,  however,  the  symptoms  of  the 
patient  and  the  appearance  of  the  breast  show  that  pus  has 
formed,  it  must  be  evacuated  without  delay,  as  every  hour  that 
it  is  left  in  the  breast  means  a  further  destruction  of  the  gland. 

A  mammary  abscess,  if  opened  as  soon  as  it  forms,  and  correctly 
treated,  is  comparatively  easy  to  cure,  while  one  which  has  been 
neglected  and  is  then  opened  and  drained  through  a  small 
incision  is  a  most  tedious  condition  and  may  continue  to  discharge 
pus  for  weeks.  In  all  cases,  unless  the  abscess  is  minute  and 
superficial,  the  patient  must  be  placed  under  an  anaesthetic,  as 
it  is  impossible  to  carry  out  sufficiently  radical  measures  by  means 
of  local  anaesthesia.  An  incision  radiating  from  the  nipple  and 
of  sufficient  length  to  allow  the  finger  to  be  passed  through  it 
into  the  cavity,  is  then  made  over  the  most  superficial  part  of  the 
abscess.  The  pus  is  allowed  to  escape,  and  as  soon  as  it  has 
done  so,  the  finger  is  introduced  into  the  cavity,  and  all  the  septa 
intervening  between  the  loculi  in  which  the  pus  is  collected,  are 
broken  down,  so  that  instead  of  a  number  of  small  cavities  one 
large  cavity  is  formed.  This  cavity  is  then  curetted  out  with 
a  large  and  blunt  flushing  curette,  through  which  a  stream  of 
hot  antiseptic  lotion  is  flowing,  and  all  broken  down  debris 
removed.  As  soon  as  this  is  done,  the  cavity  is  dried,  and  tightly 
plugged  with  iodoform  gauze.  The  breast  is  then  firmly  bandaged 
to  the  chest  wall.  The  next  day  the  plug  is  removed,  the  cavity 
douched  out,  and  a  fresh  plug  inserted,  and  this  procedure  is 
adopted  daily  until  the  temperature  falls  to  normal,  and  the 
discharge  of  pus  has  almost  ceased.  As  soon  as  this  occurs, 
the  plugging  of  the  cavity  may  be  stopped,  a  piece  of  gauze 
placed  in  the  opening,  and  the  breast  firmly  bandaged  in  such 
a  manner  as  to  bring  the  walls  of  the  cavity  into  apposition.  The 
breast  need  not  then  be  dressed  for  a  couple  of  days,  and  at  the 
end  of  that  time,  it  will  probably  be  found  that  the  cavity  is 
almost  obliterated,  and  that  only  the  opening  where  the  gauze 
was  placed  is  left.     The   final  closure  of  this  opening  may  be 


PULMONARY  EMBOLUS  949 

hastened  by  a  stimulating  dressing,  such  as  compound  tincture 
of  benzoin.  It  is  surprising  how  rapidly  even  very  bad  cases  of 
mammary  abscess  get  well  under  this  treatment,  and  cases,  which 
under  the  old  treatment  of  simple  incision  and  drainage  would 
have  taken  from  four  to  six  weeks  to  cure,  are  completely  healed 
in  from  one  to  two  weeks. 


PULMONARY  EMBOLUS 

Embolism  of  the  pulmonary  artery  may  occur  subsequent  to 
delivery  in  consequence  of  the  detachment  of  a  clot  from  some 
part  of  the  venous  system  and  its  passage  through  the  right  side 
of  the  heart  into  the  pulmonary  artery.  As  a  rule,  the  clot  forms 
after  delivery  in  a  dilated  uterine  sinus  or  in  one  of  the  large 
pelvic  veins  in  which,  owing  to  enfeebling  of  the  heart's  action, 
the  blood  is  circulating  slowly.  Such  clotting  is  favoured  by  in- 
complete retraction  of  the  uterus  and  the  consequent  dilatation 
of  the  uterine  sinuses ;  by  septic  infection  of  the  uterine  wall 
extending  into  the  pelvic  veins ;  and  by  post-partum  haemor- 
rhage, unduly  prolonged  labour,  or  other  cause  of  weakening  of 
the  heart's  action. 

Symptoms. — The  symptoms  of  pulmonary  embolus  occurring 
during  the  puerperium  are  identical  with  the  symptoms  to  which 
this  condition  gives  rise  at  other  times.  Their  onset  is  ex- 
tremely rapid.  The  condition  of  the  patient  may  be  at  one 
moment  apparently  normal,  and  then  all  at  once,  following  perhaps 
on  some  slight  movement,  she  becomes  collapsed,  asphyxiated, 
her  breathing  rapid  and  shallow,  and  the  action  of  her  heart  so 
fast  and  feeble  as  to  be  almost  or  quite  uncountable.  If  the  clot 
completely  fills  the  main  trunk  of  the  artery,  death  is  almost 
instantaneous,  while,  if  it  lodges  in  the  main  trunk  but  does  not 
completely  fill  it,  death  may  result  in  from  some  minutes  to  some 
hours.  If  a  branch  alone  of  the  artery  is  plugged,  the  symptoms 
are  not  so  severe,  and,  if  the  patient  survives  the  first  few  hours, 
she  may  possibly  recover. 

Treatment. — The  patient  should  be  supported  in  a  sitting  posture 
by  pillows,  as  in  this  position  she  will  breathe  most  easily.  The 
action  of  the  heart  must  be  stimulated  and  strengthened  by  the 
hypodermic  injection  of  strychnine,  and  ether.  Oxygen,  if  at 
hand,  should  be  inhaled.  Ammonia  is  especially  recommended, 
both  as  a  stimulant  and  on  the  ground  that  it  may  assist  the 
absorption  of  the  clot,  or  at  any  rate  prevent  further  thrombosis. 
It  may  be  given  as  the  carbonate  of  ammonia  in  five-grain  doses, 
or  as  the  aromatic  spirit,  in  half-drachm  doses,  at  first  every 
hour,  and  subsequently  less  frequently.  If  the  right  side  of  the 
heart  is  engorged,  as  shown  by  marked  cyanosis  and  fulness  of 
the  superficial  veins,  venesection  to  the  extent  of  a  few  ounces, 
or  the  application  of  leeches  often  gives  considerable  relief.     Such 


950  PATHOLOGY  OF  THE  PUERPERIUM 

remedies  are,  however,  alone  of  use  where  the  vessel  plugged  is  of 
small  size;  if  the  main  trunk  is  involved,  the  prognosis  is  abso- 
lutely bad. 


SUB-INVOLUTION  OF  THE  UTERUS 

Sub-involution  of  the  uterus  is,  as  the  name  implies,  the  con- 
dition in  which  the  normal  involution  of  the  uterus  does  not  occur, 
and  in  which,  accordingly,  an  enlarged  and  relaxed  condition 
persists  long  after  the  organ  should  have  returned  to  its  normal 
unimpregnated  condition.  Sub-involution,  strictly  speaking,  is 
more  a  gynaecological  than  an  obstetrical  condition,  but  it  is 
customary  to  refer  to  it  in  works  on  obstetrics. 

ALtiology. — The  causes  of  sub-involution  may  be  briefly  stated 
to  include  anything  that  predisposes  to  abnormal  and  persistent 
hyperemia  of  the  uterus  during  the  puerperium.  The  most 
common  of  such  conditions  are  leaving  bed  too  soon  after  delivery, 
or  too  much  exercise  or  work  even  when  the  patient  has  not  left 
her  bed  prematurely  ;  the  presence  of  a  backward  displacement  of 
the  uterus  ;  the  retention  of  portions  of  placenta  and  membranes  ; 
and  putrid  or  septic  endometritis.  Nine-tenths  of  all  cases  are 
probably  due  to  leaving  bed  too  soon  and  the  downward  displace- 
ment of  the  heavy  uterus,  leading  to  its  congestion.  It  is  question- 
able whether  backward  displacements  should  be  regarded  as  the 
cause  or  the  consequence  of  sub-involution.  In  many  cases,  the 
displacement  is  due  to  the  abnormal  size  of  the  uterus,  and  so  is 
the  result  of  the  sub-involution  ;  but,  in  other  cases — and  we 
desire  to  draw  attention  to  the  importance  of  this,  backward 
displacements  of  the  uterus  occur  without  any  noticeable  symptom 
of  pre-existing  sub-involution,  and,  in  such  cases,  the  involution  of 
the  uterus  usually  ceases.  The  retention  of  portions  of  the  ovum 
or  the  occurrence  of  endometritis  naturally  causes  congestion. 
Rarer  causes  of  sub-involution  are  the  presence  of  tumours  such 
as  small  myomata,  and  possibly  a  very  short  labour  in  which 
the  normal  degree  of  retraction  of  the  uterine  fibres  has  not 
occurred. 

Symptoms. — The  earliest  symptom  of  sub-involution  is  the  per- 
sistence of  the  lochia  beyond  the  normal  period.  Later,  the  symp- 
toms consist  in  the  occurrence  of  leucorrhcea,  in  constant  backache 
and  bearing-down  sensations,  and  in  the  presence  of  an  enlarged 
and  soft  uterus,  which,  as  a  rule,  lies  lower  in  the  pelvis  than 
it  ought  to  do,  and  which  may  be  displaced  backwards.  In  any 
case  in  which  the  lochia  remain  red  after  the  tenth  day,  or  in 
which  the  fundus  is  found  above  the  level  of  the  symphysis  after 
the  ninth  day,  sub-involution  is  the  probable  cause.  In  estimating 
the  height  of  the  fundus,  however,  it  must  be  remembered  that  a 
loaded  rectum  or  a  full  bladder  may  push  the  uterus  into  an 
unduly  high  position,  and  so  make  it  appear  to  be  enlarged. 


SUB-INVOLUTION  OF  THE  UTERUS  951 

Treatment. — The  prophylactic  treatment  of  sub-involution  con- 
sists in  the  conduction  of  the  third  stage  of  labour  in  such  a 
manner  that  placental  fragments  are  not  left  behind  in  the  uterus, 
in  attention  to  the  regular  emptying  of  the  bladder  and  rectum 
during  the  puerperium,  in  keeping  the  patient  in  bed  for  a 
sufficient  period  after  delivery,  and  in  replacing  any  displace- 
ments of  the  uterus  that  may  occur.  Backward  displacement  of 
the  puerperal  uterus  may  occur  without  any  apparent  cause,  and 
is  presumably  due  to  undue  relaxation  of  the  uterine  ligaments. 
When  it  does  occur  it  stops  involution,  but  this  will  again  continue 
if  the  uterus  is  replaced.  It  is,  therefore,  very  essential  if  the 
symptoms  of  the  patient  point  to  the  existence  of  a  backward 
displacement  to  examine  her,  and,  if  a  displacement  is  found,  to 
replace  it  and  maintain  the  uterus  in  position  by  tampons  which 
are  changed  every  day,  or  by  a  suitable  pessary.  If  a  pessary  is 
inserted  in  such  cases,  it  should  be  the  smallest  that  will  keep 
the  uterus  in  position.  It  may  usually  be  removed  in  a  few 
weeks,  as,  once  involution  has  occurred,  the  uterus  will  remain 
in  its  proper  position.  If,  however,  the  displacement  has  been 
allowed  to  remain  uncorrected  for  weeks  or  months,  the  ligaments 
will  have  become  permanently  lengthened,  and  it  will  probably 
be  necessary  for  the  patient  to  wear  the  pessary  for  a  considerable 
time. 

If  sub-involution  is  present,  any  causal  factor  must  be  removed, 
and  the  patient  kept  in  bed.  Hot  vaginal  douches  may  be 
administered  daily,  and,  if  there  is  a  persistence  of  red  lochia, 
it  is  well  to  wash  out  the  uterus  as  well.  If  there  is  any  reason 
to  suspect  that  fragments  of  the  ovum  or  decidua  have  been 
left  behind,  the  uterus  must  be  explored  with  the  finger  or  a  blunt 
curette,  and  the  retained  fragments  removed.  In. cases  in  which 
the  lochia  still  persist,  and  are  principally  blood,  we  have  obtained 
good  results  by  the  injection  of  half  a  drachm  or  a  drachm  of  a 
fifty  per  cent,  solution  of  formalin.  The  latter  is  injected  by 
means  of  a  Braun's  syringe,  and  the  uterus  immediately  washed 
out  with  water.  All  that  is  desired  is  to  obtain  the  momentary 
action  of  the  formalin  on  the  endometrium,  and  on  no  account 
must  it  be  allowed  to  remain  in  the  uterine  cavity,  as  its  caustic 
action  is  too  great.  Formalin  causes  uterine  contraction,  and 
also  helps  to  bring  about  a  healthy  condition  of  the  inside  of 
the  uterus  by  hastening  the  discharge  of  any  remaining  fragments 
of  decidua.  It  may  give  rise  to  pain  for  a  few  hours  after  it  has 
been  used,  due  probably  to  the  contractions  it  induces. 

In  addition  to  the  use  of  local  measures,  ergot  may  be 
administered  internally.  As  a  rule,  it  is  best  to  give  a  few 
fairly  large  doses  of  half  a  drachm  or  a  drachm  of  the  liquid 
extract,  or  a  pill  containing  ergot  and  strychnine  (Strychnine, 
gr.  ^j ;  Ext.  Ergotae,  grs.  iii.),  may  be  given  night  and  morning 
for  a  week. 

The  future  well-being  of  the  patient  depends  to  a  very  large 


952  PATHOLOGY  OF  THE  PUERPERIUM 

extent  on  the  due  occurrence  of  normal  involution  of  the  uterus, 
its  ligaments,  and  of  the  pelvic  floor  and  vagina,  and  consequently 
it  is  to  the  highest  degree  important  that  any  failure  in  that 
process  should  be  at  once  determined,  and  correctly  treated. 


SUPER-IN VOLUTION  OF  THE  UTERUS 

Super-involution  is  the  opposite  of  sub-involution.  It  is  the 
condition  in  which  the  process  of  involution  is  carried  to  too  great 
an  extent,  vrith  the  result  that  the  uterus  is  reduced  to  an 
abnormally  small  size.  It  is,  in  other  words,  a  post-puerperal 
atrophy  of  the  uterus. 

^-Etiology. — The  usually  accepted  cause  of  super-involution  is 
the  association  of  prolonged  lactation  with  a  debilitated  condition 
of  the  woman.  Lactation  has  a  well-recognised  effect  on  the 
occurrence  of  uterine  contraction.  At  first,  every  time  the  infant 
is  put  to  the  breast  contractions  follow,  and  it  is  possible  that  in 
some  cases  the  occurrence  of  such  contractions  may  persist 
during  lactation,  and  may  be  largely  responsible  for  the  atrophy 
by  unduly  limiting  the  uterine  blood- supply.  Super-involution 
may  also  occur  in  consequence  of  the  complete  or  partial  destruc- 
tion of  the  ovarian  structure  by  inflammatory  changes. 

Symptoms. — The  symptoms  of  super-involution  differ  from  those 
of  sub-involution  in  that,  while  the  latter  usually  appear  during 
the  first  month  or  two  after  delivery,  the  former  do  not  appear 
until  after  a  lapse  of  several  months.  In  all  cases,  the  symptoms 
are  very  slight,  and  are  practically  limited  to  the  non-appearance 
of  the  menses  even  after  lactation  has  ceased.  As  a  rule,  the 
patient  seeks  advice  on  account  of  her  debilitated  condition  or  of 
the  persistence  of  amenorrhoea,  and  the  atrophy  is  only  discovered 
accidentally,  if  a  bi-manual  examination  is  made.  The  uterus  in 
a  typical  case  is  reduced  to  half  its  normal  size,  but,  in  exag- 
gerated cases,  it  may  be  considerably  smaller  than  this.  Thus, 
A.  R.  Simpson  described  a  case  in  which  the  cavity  was  reduced 
to  a  quarter  of  an  inch  in  length.  In  many  instances,  the  con- 
dition is  only  temporary,  and  the  uterus  returns  to  its  normal 
size  as  soon  as  lactation  is  stopped. 

Treatment. — The  treatment  consists  in  the  improvement  of  the 
general  health  of  the  patient  and  in  stopping  lactation.  Plenty 
of  good  nourishing  food,  the  administration  of  iron  and  cod-liver 
oil,  and  change  of  air,  will  usually  bring  about  a  return  to  the 
normal  condition.  In  cases  in  which  the  atrophy  is  due  to 
destruction  of  the  ovaries,  and  is  practically  the  premature  onset 
of  the  menopause,  treatment,  as  is  to  be  expected,  is  of  no  avail, 
save  in  improving  the  general  health  of  the  patient. 


PART    IX 
OBSTETRICAL    OPERATIONS 


CHAPTER  I 
VARIOUS  OBSTETRICAL  OPERATIONS 

Accouchement  Force — Artificial  Dilatation  of  the  Cervix  by  Incision,  by  Instru- 
mental Dilatation,  by  Manual  Dilatation  —  Curetting — Induction  of 
Abortion — Induction  of  Premature  Labour  ;  Krause's  Method,  Podalic 
Version  and  Rupture  of  the  Membranes,  Tamponade  of  Vagina,  Intra- 
uterine Injections,  Dilatation  of  the  Cervix,  Rupture  of  the  Membranes 
— The  Manual  Removal  of  the  Placenta — The  Suture  of  Cervical  Lacera- 
tions— The  Suture  of  Perinaeal  and  Vaginal  Lacerations — Tamponade  of 
the  Genital  Tract. 


ACCOUCHEMENT  FORCE 

Accouchement  force  is  the  term  applied  to  the  rapid  dilatation  of 
the  cervical  canal  to  a  size  sufficient  to  permit  the  passage  of  the 
foetus,  the  performance  of  podalic  version,  and  the  extraction  of 
the  foetus  as  a  pelvic  presentation. 

Indications. — The  indications  for  accouchement  force  cannot  be 
definitely  laid  down,  as  they  differ  to  a  very  great  extent  according 
to  the  teaching  of  different  schools.  Some  ten  to  thirty  years 
ago,  accouchement  force  was  a  comparatively  frequent  operation, 
and  was  recommended  and  frequently  performed  in  ante-partum 
haemorrhages,  in  eclampsia,  and  in  other  obstetrical  complica- 
tions. In  consequence  of  the  high  mortality  to  which  it  gave  rise, 
the  operation  then  fell  into  disrepute,  and  was  condemned  by 
many  of  the  highest  authorities.  Of  late,  however,  in  consequence 
of  improvements  in  its  technique,  and  in  a  more  general  apprecia- 
tion of  the  necessity  for  and  the  means  of  obtaining  asepsis,  the 
operation  has  been  again  brought  forward,  and,  so  far  as  we 
can  at  present  judge,  has  been  adopted  with  benefit  under  certain 
circumstances.  Speaking  generally,  accouchement  force  is  indicated 
in  certain  cases  of  eclampsia  and  of  grave  organic  disease  of  the 
mother,  in  which  not  alone  is  it  considered  inadvisable  to  allow 
pregnancy  to  continue,  but  in  which  the  condition  of  the  patient 
makes  it  unwise  to  wait  for  the  onset  of  induced  labour. 

Operation. — The  operation  consists  of  three  steps: — First,  dilata- 
tion of  the  cervix  ;  secondly,  podalic  version  ;  thirdly,  extraction 
of  the  foetus. 

955 


956  OBSTETRICAL  OPERATIONS 

Dilatation  of  the  cervix  in  the  classical  operation  was  performed 
manually,  but  the  use  of  the  fingers  for  this  purpose  has  been 
now  replaced  to  a  great  extent  by  the  class  of  mechanical  dilators 
of  which  Bossi's  dilator  was  the  first.  The  method  of  performing 
dilatation  will  be  presently  described.  As  soon  as  the  cervical 
canal  is  sufficiently  dilated  to  admit  the  hand,  the  latter  is  passed 
into  the  uterus,  and  a  foot  is  grasped  and  drawn  down  into 
the  vagina.  The  method  in  which  the  foetus  is  extracted  will 
be  subsequently  described  under ,  the  heading  of  extraction  in 
pelvic  presentation.  The  initial  steps  of  bringing  the  breech 
through  the  cervix  must  be  performed  slowly  and  carefully,  in 
order  that  the  cervix  may  be  dilated  without  laceration.  As 
soon,  however,  as  the  umbilicus  appears  at  the  vulva,  the 
remaining  steps  of  the  extraction  must  be  rapidly  performed,  as 
otherwise  the  foetus  will  be  asphyxiated  during  the  passage  of 
the  head  through  the  pelvis. 


ARTIFICIAL  DILATATION  OF  THE  CERVIX 

Obstetrical  dilatation  of  the  cervix,  as  distinct  from  gynaeco- 
logical dilatation,  can  be  effected  by  one  of  the  following 
methods  : — By  incision  of  the  cervix  ;  by  instrumental  dilatation  ; 
and  by  manual  dilatation. 

By  Incision  of  the  Cervix. — Dilatation  of  the  cervix,  by 
means  of  multiple  incisions,  was  introduced  by  Duhrssen/''  who 
says  that  it  constitutes  an  easy  and  efficient  method  of  obtaining 


Fig.  385. — Martin's  Whole-curved  Needles. 


the  necessary  dilatation  for  delivering  the  foetus  in  cases  in  which 
the  whole  supra-vaginal  portion  of  the  cervix  is  already  fully 
dilated,  and  in  which  the  defective  dilatation  is  limited  to  the 
vaginal  portion.  This  condition  is  usually  alone  found  in  primi- 
parse,  in  whom  the   supravaginal    portion  of   the  cervix   dilates 

*   '  Uber  den  Werth  der  tiefen  Cervix  und  Scheiden-Damm  Einschnitte  in 
der  Geburtschiilfe,'  Archiv  f.  Gyn.,  1890,  vol.  xxxvii.,  pp.  27-66. 


DILATATION  BY  INCISION  OF  THE  CERVIX 


957 


first.  In  multiparae,  on  the  other  hand,  the  supravaginal  portion 
dilates  at  a  later  period  of  labour,  and  consequently  in  their  case 
it  is  rarely  possible  to  perform  this  operation. 

Indications. — Incision  of  the  cervix  is  indicated  in  the  following 
cases  : — 

(i)  Stenosis  of  the  vaginal  portion  of  the  cervix,  which  will  not 
yield  to  the  use  of  sedatives  and  hot  douches. 


Fig.  386. — Martin's  Needle-holder. 

(2)  In  cases  in  which  immediate  delivery  is  indicated,  in  which 
the  supravaginal  portion  of  the  cervix  is  dilated  but  the  vaginal 
portion  is  not,  and  in  which  dilatation  cannot  be  effected  by 
Frommer's  dilator.  w"- 

Instruments. — The  following  instruments  are  necessary  : — A 
posterior  speculum;  a  stout,  blunt-pointed  scissors;  Martin's 
needle-holder ;  silk ;  whole-curved  needles  of  medium  and  small 
size  ;  two  or  three  American  bullet  forceps. 


Fig.  387. — A  Posterior  Speculum. 


Operation. — The  patient  is  placed  in  the  cross-bed  position,  and 
the  vagina  is  thoroughly  douched.  The  posterior  margin  of  the 
cervix  is  then  seized  with  two  American  forceps,  one  a  little  to 
each  side  of  the  middle  line.  The  piece  of  cervix  lying  between 
them  is  then  taken  between  the  middle  and  index  fingers  of  the 
left  hand,  the  former  finger  in  the  vagina,  the  latter  in  the  cervical 
canal.  The  fingers  should  reach  right  up  to  the  vaginal  insertion. 
The  points  of  the  scissors  are  then  pushed  along  the  fingers,  and 
the  cervix  divided.  Then  the  lateral  margin  of  the  cervix  is 
similarly  seized,  each  side  in  turn,  and  divided,  and  lastly  the 
anterior  margin.     In  cases  in  which  there  is  extreme  rigidity  of 


95§ 


OBSTETRICAL  OPERATIONS 


the  cervical  tissues  from  structural  change,  it  may  be  necessary 
to  make  additional  incisions  between  the  original  four.  If  so, 
they  are  made  in  a  similar  manner.  Each  incision  can,  as  a  rule, 
be  made  with  two  cuts  of  the  scissors,  and  should  extend  right 
up  to  the  vaginal  insertion. 

After  the  delivery  of  the  child,  Diihrssen  recommends  plugging 
the  utero-vaginal  canal  or  the  vagina  alone,  if  there  is  any 
haemorrhage,  and  he  does  not  consider  that  it  is  necessary  to 
suture   the  incisions.     We,  however,  prefer   to  suture  them,  in 


Fig.  388. — An  American  Forceps. 

order  to  avoid  a  subsequent  ectropion.  The  suturing  presents 
but  little  difficulty  if  the  cervix  is  well  depressed  by  traction  with 
forceps  and  by  pressure  on  the  fundus.  If  it  is  decided  to  suture, 
each  incision  is  closed  by  two  or  three  sutures  passed  at  right 
angles  to  the  incisions.  These  sutures  should  be  removed  in  ten 
days. 

By  Instrumental  Dilatation. — There  are  two  classes  of 
dilators  which  are  intended  for  use  in  obstetrical  cases.  These 
are  : — 

(1)  Metal  dilators,  with  four  or  more  eccentric  limbs,  of  which 
Bossi's  dilator  is  the  prototype. 


Fig.  389. — Bossi's  Dilator,  the  Blades  closed. 

(2)  Hydrostatic  dilators,  of  which  Barnes'  dilator  is  the  proto- 
type. 

One  of  the  best  patterns  of  metal  dilator  for  use  in  obstetrical 
practice  is  Frommer's  modification  of  Bossi's  dilator  {v.  Figs. 
389-391).  As  seen  in  the  illustration,  it  consists  of  eight  limbs, 
the  points  of  which  can  be  divaricated  eccentrically  by  means 
of  a  screw  handle.  An  indicator  at  the  side  shows  the  exact 
degree  of  dilatation   which  has   been    obtained.      The  limbs  of 


INSTRUMENTAL  DILATATION  OF  THE  CERVIX 


959 


the  instrument  are  all  detachable,  and  can  be  readily  cleaned. 
The  presence  of  eight  limbs  prevents  undue  pressure  on  the 
cervix  at  any  point,  and  enables  the  cervix  to  be  dilated  gradually 
and   without    laceration.      For    this    reason,    it    has   a   manifest 


Fig.  390. — Bossi's  Dilator,  the  Blades  partly  open. 

advantage  over  Bossi's  dilator,  which  has  only  four  limbs.  The 
instrument  is  as  yet  too  new  to  pronounce  definitely  for  or  against 
its  use,  but  judging  solely  from  a  mechanical  point  of  view,  and 
from  the  published  results  of  cases  treated  by  it,  it  appears  to  be 


Fig.  391. — Frommer's  Dilator,  the  Blades  open. 

very  perfect,  and  to  have  most  successfully  carried  out  the  object 
for  which  it  was  designed. 

The   most    recent   pattern    of    dilator    is   that   introduced   by 
De  Seigneux  (v.  Fig.  392).     It  differs  from  its  predecessors  in 


Fig.  392. — De  Seigneux's  Dilator. 
A,  The  blades  closed  ;  B,  the  blades  open. 

three  respects.  First,  that  the  dilating  part  of  each  blade  is  set 
at  an  angle  to  the  remainder  of  the  blade.  Secondly,  that  sets 
of  blades  of  different  sizes  can  be  adjusted  to  the  same  handle. 
Thirdly,  that  the  blades  can  be  introduced  separately. 


960 


OBSTETRICAL  OPERATIONS 


De  Seigneux  states  that  the  advantages  of  his  dilator  are 
as  follows  : — 

(1)  It  is  possible  to  adapt  to  the  same  handle,  according  to  the 
progress  of  dilatation,  a  succession  of  blades  of  wider  surface  in 
such  a  way  as  to  reduce  to  a  minimum  the  risk  of  laceration  of 
the  cervix. 

(2)  Owing  to  the  fact  that  the  dilatation  is  effected  in  a  plane 
parallel  to  the  axis  of  the  instrument,  the  dilator  presents  a 
pelvic  curve  in  the  obstetrical  sense  of  the  word,  and  so  it  is 
possible  to  bring  the  dilating  part  of  the  instrument  into  the 
plane  of  the  pelvic  inlet.  In  consequence,  the  uterine  orifice 
undergoes  no  dislocation. 

(3)  The  instrument  is  so  constructed  that  each  blade  can  be 
introduced  separately,  and  can  be  fixed  to  the  handle  when  it  is 
in  position.  This  permits  the  use  of  larger  blades  than  those 
which  are  employed  in  the  Bossi  dilator  and  other  instruments 
of  the  same  kind.  De  Seigneux  has  a  series  of  blades  for  his 
own  use  varying  from  o-6  cm.,  1*2  cm.,  2-4  cm.,  3*6  cm.  in  width. 


Fig 


393. — The  Dilating  Portion  of  the  Blades,  showing  the 
Relative  Sizes  of  the  Different  Sets. 


The  points  of  the  blades  measure  respectively  in  width: — A,  06  cm.,  or 
J  inch;  B,  12  cm.,  or  \  inch;  C,  24  cm.,  or  1  inch;  D,  36  cm.,  or 
1^  inches. 

(4)  As  soon  as  dilatation  has  been  effected,  the  blades  can  be 
withdrawn  one  after  the  other,  and  so  the  removal  of  the  instru- 
ment cannot  be  obstructed  by  the  descent  of  the  head  during  the 
operation. 

The  following  are  stated  to  be  the  advantages  of  dilators  of 
the  Bossi  type  : — 

(1)  They  can  be  applied  in  the  case  of  a  cervix  in  which  neither 
dilatation  nor  taking  up  has  commenced. 

(2)  They  enable  a  sufficient  degree  of  dilatation  to  be  obtained 
to  permit  the  delivery  of  a  full-term  fcetus. 

(3)  They  enable  this  degree  of  dilatation  to  be  obtained  rapidly, 
if  necessary  in  from  fifteen  to  twenty  minutes. 

(4)  They  excite  uterine  contractions,  even  in  a  uterus  suffering 
from  inertia. 

Two  forms  of  hydrostatic  dilator  are  in  general  use — Champetier 


INSTRUMENTAL  DILATATION  OF  THE  CERVIX 


961 


de  Ribes',  and  Barnes'.  The  former  of  these  is  preferable,  inas- 
much as  the  manipulations  necessary  for  its  use  are  less  than  in 
the  case  of  Barnes'  dilators.  Champetier  de  Ribes'  hydrostatic 
dilator  consists  of  a  conical  bag  made  of  inelastic  water-proofed 


Fig.  394. — Champetier  de  Ribes'  Hydrostatic  Dilator,  and  Forceps 
for  inserting  it. 

silk  (v.  Fig.  394).  The  base  of  the  bag  measures  three  and  a  half 
inches,  and  the  bag  tapers  through  a  length  of  six  inches  to  a 
diameter  of  half  an  inch.     It  is  slightly  curved  to  suit  the  curve 


Fig.  395. — Barnes'  Hydrostatic  Dilator,  and  Syringe  for  filling  it. 

of  the  genital  canal,  and  its  fluid  capacity  is  about  twenty-two 
ounces.  Barnes'  hydrostatic  dilators  are  fiddle-shaped  rubber  bags 
of  varying  size,  the  smallest  of  which  is  introduced  first,  followed 
in  turn  by  the  others  according  as  the  os  dilates  (v.  Fig.  395). 

61 


962  OBSTETRICAL  OPERATIONS 

Indications.— Instrumental  dilatation  of  the  cervix  is  indicated 
in  the  following  conditions  : — 

(i)  In  cases  of  pelvic  contraction,  when,  owing  to  the  early 
rupture  of  the  membranes  and  the  slow  advance  of  the  presenting 
part,  the  cervix  is  not  dilating,  and  when  delivery  per  vaginam  is 
possible. 

(2)  In  cases  of  stenosis  of  the  cervix  which  will  not  yield  to  the 
use  of  sedatives  and  hot  douches. 

(3)  In  certain  complications  of  pregnancy  and  labour  when  it 
is  desired  to  effect  rapid  delivery.  Amongst  these  complications 
may  be  mentioned  certain  cases  of  eclampsia,  concealed  accidental 
haemorrhage,  grave  renal,  pulmonary,  or  cardiac  complications, 
and  the  presence  of  a  dead  and  putrid  foetus. 

(4)  Champetier's  dilator  is  recommended  in  certain  cases  of 
placenta  praevia  (Duhrssen,  Blacker).  We  do  not  recommend  its 
general  use  for  this  purpose. 

Instruments. — If  Frommer's  dilator  is  used,  no  other  instrument 
is  required.  If  Champetier  de  Ribes'  dilator  is  used,  a  slightly 
curved  narrow  bladed  and  fenestrated  forceps,  for  introducing  the 
dilator,  is  also  required. 

Operation. — The  patient  is  placed  in  the  dorsal  cross-bed  position, 
and  the  vagina  is  thoroughly  douched.  If  Frommer's  dilator  is  used, 
it  is  passed  closed  through  the  cervical  canal,  and  then  by  turning 
the  handle  the  blades  are  very  slowly  and  gradually  divaricated. 
After  each  quarter  or  half  turn  of  the  handle,  a  couple  of  minutes' 
interval  should  be  allowed,  and  the  entire  process  of  dilatation, 
in  cases  in  which  the  os  was  completely  closed,  should  take  from 
thirty  minutes  to  an  hour.  During  the  process  of  dilatation,  the 
vagina  should  be  douched  from  time  to  time  with  hot  lysol 
lotion,  as  this  tends  to  increase  the  softness  and  dilatability  of  the 
cervical  tissues. 

If  Champetier's  dilator  is  used,  it  is  first  sterilised  by  boiling, 
then  folded  along  its  long  axis,  caught  in  the  forceps,  and  passed 
gently  upwards  through  the  uterine  orifice.  If  the  orifice  is  not 
of  sufficient  size  to  permit  of  the  introduction  of  the  forceps,  it 
must  be  previously  dilated  with  Hegar's  dilators.  If  the  uterine 
orifice  is  of  sufficient  size,  it  is  advisable  to  pass  the  tips  of  the 
fingers  through  the  orifice,  and  to  guide  the  forceps  in  between 
them.  The  bag  should  penetrate  from  four  to  four  and  a  half  inches 
(10  to  1 1  cms.)  within  the  internal  os.  The  douche  is  then  attached 
to  the  nozzle  of  the  dilator  and  allowed  to  flow,  taking  care  that 
there  is  a  sufficient  head  of  water.  As  the  dilator  fills,  the  forceps 
is  gradually  opened,  and  is  withdrawn  as  soon  as  the  dilator  is  of 
sufficient  size  to  prevent  the  latter  from  being  drawn  out  along 
with  it.  If  sufficient  pressure  cannot  be  obtained  to  make  the  water 
flow,  a  new  Higginson's  syringe  must  be  used.  It  is  best  to  use 
a  one  per  cent,  solution  of  carbolic  acid  in  water  for  filling  the 
dilator.  According  to  the  inventor,  if  22-4  ounces  are  injected 
into  the   dilator,  the   latter  has    a  maximum   circumference  of 


MANUAL  DILATATION  OF  THE  CERVIX 


963 


13  inches  (33  cms.);  if  18-9  ounces  are  injected,  of  io'6  inches 
(27  cms.);  if  15-4  ounces  are  introduced,  of  87  inches  (22  cms.). 
As  the  circumference  of  the  full-term  fcetal  head  is  about  thirteen 
inches,  it  will  be  seen  that  in  vertex  presentations  the  dilator  will 
require  to  be  filled  to  almost  its  full  extent.  As  soon  as  the  uterine 
orifice  is  of  sufficient  size,  the  dilator  is  expelled  by  the  uterine 
contractions. 

By  Manual  Dilatation. — Manual  dilatation  of  the  cervix  is 
the  oldest  method  in  use,  and,  though  in  the  majority  of  cases  it 


Fig.  396.— The  Different  Stages  in  Harris'  Method  of  Manual 
Dilatation  of  the  Cervix.     (Harris.) 

has  been  replaced  by  mechanical  dilators,  still  it  sometimes  may  be 
found  of  advantage,  especially  in  view  of  the  fact  that  no  special 
apparatus  is  required.  The  usual  method  of  carrying  it  out  con- 
sists in  placing  the  patient  in  the  dorsal  cross-bed  position,  and  in 
introducing  first  the  index  finger  into  the  cervix,  then  the  index 
and  middle  finger,  then  three  fingers,  then  four  fingers,  and  finally 
the  entire  hand,  which  is    passed    gently  upwards  through  the 

61 — 2 


964  OBSTETRICAL  OPERATIONS 

uterine  orifice  in  the  form  of  a  cone.  In  each  case,  room  for 
the  additional  finger  is  made  by  forcibly  separating  the  fingers 
which  have  already  been  introduced.  A  modification  of  this 
method  has  been  introduced  by  Harris,*  and  appears  to  offer 
certain  advantages.  Whitridge  Williams  strongly  advocates  it  and 
considers  it  preferable  to  the  use  of  instrumental  or  hydrostatic 
dilators.  To  perform  it,  the  hand  lubricated  with  lysol,  or  some 
aseptic  lubricant,  is  introduced  into  the  vagina,  and  the  index 
finger  pushed  upwards  through  the  internal  os.  Then  the 
index  and  second  fingers  are  passed  into  the  cervical  canal  and 
gradually  pushed  through  the  inner  os,  which  is  correspondingly 
dilated  (v.  Fig,  396).  As  soon  as  this  has  been  done,  the  remainder 
of  dilatation  is  said  to  be  comparatively  easy.  The  index  finger 
and  the  thumb  are  passed  through  the  inner  os,  and  forcibly 
separated  from  one  another  by  a  movement  similar  to  that  made 
when  '  snapping '  the  fingers.  This  done,  the  thumb  and  the 
index  and  middle  fingers  are  introduced,  and  the  thumb  and 
fingers  again  separated  in  the  same  manner.  Then  the  thumb  and 
three  fingers,  and  finally  the  thumb  and  four  fingers  are  succes- 
sively introduced.  The  method  is  clearly  shown  in  the  accom- 
panying drawings.  According  to  Williams,  when  the  internal  os 
is  obliterated,  dilatation  of  the  remainder  of  the  uterine  orifice  can 
be  effected  in  a  few  minutes  by  this  method,  and,  in  suitable  cases, 
when  the  internal  os  only  admits  the  tip  of  the  index-finger  dilata- 
tion can  be  effected  within  half  an  hour.  He,  however,  considers 
that  if  labour  has  not  set  in  and  the  cervix  is  hard  and  rigid,  the 
exertion  of  an  undue  amount  of  force  may  be  necessary,  and 
may  result  in  deep  cervical  lacerations.  He  therefore  thinks  this 
method  is  contra-indicated  in  such  cases. 

In  all  cases  of  dilatation,  the  use  of  an  anaesthetic  will  be 
probably  necessary,  and  the  most  careful  attention  to  asepsis 
is  essential.  The  latter  is  particularly  required  in  performing 
manual  dilatation  in  consequence  of  the  length  of  time  during 
which  the  fingers  must  be  kept  in  the  vagina  and  cervix. 

In  addition  to  these  two  methods  of  obtaining  dilatation  of  the 
cervix,  two  other  methods  in  common  use  in  gynaecological  practice 
may  sometimes  be  required  in  obstetrical  practice.  These  are 
rapid  dilatation  of  the  cervix  by  means  of  Hegar's  graduated 
dilators,  and  gradual  dilatation  by  means  of  sea-tangle  tents.  As 
these  methods  are  fully  described  in  gynaecological  text-books, 
we  do  not  consider  it  necessary  to  describe  them  here. 

*  '  A  Method  of  Performing  Rapid  Dilatation  of  the  Os  Uteri,'  American 
Journal  of  Obstetrics,  1894,  PP-  37~49- 


CURETTING  965 


CURETTING 


The  operation  of  curetting  is  occasionally  required  in  obstetrical 
practice  for  the  purpose  of  completely  emptying  a  uterus  in  which 
portions  of  an  ovum  have  been  left  behind. 


Fig.  397. — Rheinstadter's  Flushing  Curette. 

Indications. — Curetting  is  indicated  under  the  following  condi- 
tions : — 

(1)  Certain  cases  of  threatened  abortion  accompanied  by 
haemorrhage,  and  of  incomplete  abortion,  in  which  the  ovum 
cannot  be  expressed  or  removed  by  the  finger. 

(2)  Certain  cases  of  hydatidiform  mole. 

(3)  All  cases  of  putrid  endometritis  associated  with  the  reten- 
tion of  fragments  of  placenta  or  membranes. 

(4)  Certain  cases  of  secondary  post-partum  haemorrhage  due 
to  the  retention  of  small  portions  of  placenta  or  membranes, 
which  cannot  be  removed  with  the  finger. 

1/4.  SC 


Fig.  398. — Hegar's  Sharp  Curette. 

Instruments.  —  The  following  instruments  are  required  :  —  a 
posterior  speculum  ;  two  American  forceps  ;  Rheinstadter's  flush- 
ing curette,  or  other  form  of  blunt  curette ;  Bozemann's  double- 
channel  catheter. 

Operation.  —  The  patient  is  placed  in  the  dorsal  cross  -  bed 
position,  and,  after  preliminary  disinfection  of  the  vulva  and 
vagina,  a  speculum  is  introduced,  and  the  cervix  exposed, 
caught  by  a  forceps  on  the  anterior  lip  and  drawn  down.  The 
uterus  is  then  washed  out,  and  the  flushing  curette  attached 
to  the  douche  tube  is  introduced  into  the  uterus  and  passed 
gently  upwards  to  the  fundus,  in  order  to  ascertain  the  length  of 
the  uterus.  The  uterus  is  then  curetted  in  the  usual  manner, 
the  curette  travelling  from  the  fundus  to  the  inner  os,  and 
gradually  going  all  round  the  uterus.  The  force  with  which  it 
is  pressed  against  the  uterine  wall  must  be  graduated  according 
to  the  degree  of  softness  of  the  uterine  tissue,  and  should  be  only 
just  strong  enough  to  remove  any  placental  or  other  fragments 
projecting  from  the  wall.  In  the  case  of  a  very  soft  uterus,  it  is 
an  easy  matter  to  push  the  curette  through  the  uterine  wall,  and 
also,  in  the  case  of  a  puerperal  uterus,  it  is  quite  possible  to  scrape 


966  OBSTETRICAL  OPERATIONS 

away  portions  of  the  muscular  coat.  If  the  curetting  is  followed 
by  haemorrhage,  the  uterine  cavity  may  be  plugged  with  iodoform 
gauze,  and  the  same  course  may  with  advantage  be  adopted  in  cases 


Fig.  399. — Bozemann's  Double-channelled  Catheter. 

of  putrid  endometritis.  In  the  former  case,  the  gauze  may  be 
allowed  to  remain  in  situ  for  twelve  to  twenty-four  hours.  In  the 
latter  case,  it  must  not  remain  for  more  than  twelve  hours. 


THE  INDUCTION  OF  ABORTION 

The  term  induction  of  abortion  is  applied  to  the  bringing  on 
of  labour  before  the  foetus  is  viable,  i.e.,  before  the  28th  week. 
It  must  be  understood  that  the  term  is  only  applicable  in  cases 
in  which,  but  for  the  intervention,  pregnancy  would  have  con- 
tinued to  term,  and  that  it  is  not  applicable  to  cases  in  which  the 
uterus  is  emptied  in  consequence  of  the  presence  of  a  dead  ovum 
or  of  haemorrhage.  It  is  advisable  to  remember  this,  as  the 
operation  is  one  of  importance  for  ethical  and  sociological 
reasons,  and,  as  such,  differs  from  the  emptying  of  the  uterus 
in  cases  in  which  the  ovum  is  dead  or  certain  to  be  dead  in  a 
short  time.  The  induction  of  abortion,  unless  necessitated  by 
conditions  which  threaten  the  life  of  the  patient,  is  a  procedure 
contrary  to  both  the  civil  and  the  moral  law,  and  so  is  always 
open  to  adverse  criticism,  whereas  the  removal  of  an  '  inevitable 
abortion  '  is  contrary  to  neither  law,  and  is  a  procedure  the 
permissibility  of  which  has  never  been  called  in  question.  Some 
writers  have  improperly  termed  the  latter  operation  '  the  induction 
of  abortion,'  and  hence  we  consider  it  advisable  to  clearly  differ- 
entiate between  the  two. 

Indications. — The  induction  of  abortion  is  never  indicated,  save 
in  order  to  preserve  the  life  of  the  mother,  and  in  no  case  should 
a  medical  man  perform  it  solely  on  his  own  responsibility.  If  he 
considers  the  procedure  necessary,  he  should  for  his  own  protec- 
tion insist  on  a  consultation  in  order  that  he  may  be  supported 
by  the  opinion  of  another  medical  man.  The  cases  in  which  the 
procedure  is  indicated  may  be  divided  into  three  groups  : — 

(1)  Certain  cases  of  displacement  of  the  pregnant  uterus  in 
which  the  displacement  cannot  be  corrected,  and  which  cannot 
go  to  full  term.     Such  cases  are  :  — 


THE  INDUCTION  OF  ABORTION  967 

(a)  Irreplaceable  incarceration  of   the   retroverted   pregnant 

uterus. 

(b)  Irreducible  prolapse  of  the  pregnant  uterus. 

(c)  Irreducible  hernia  of  the  pregnant  uterus.     In  almost  all 

such  cases,  however,  the  uterus  can  be  replaced  by  the 
adoption  of  suitable  operative  procedures. 

(2)  Certain  diseases  of  or  accompanying  pregnancy,  which  do 
not  respond  to  treatment  and  which  threaten  the  life  of  the 
patient.  The  most  important  of  these  diseases  are  hyperemesis, 
profound  auto-intoxication,  and  certain  cases  of  serious  organic 
disease. 

(3)  Certain  cases  of  narrowing  of  the  parturient  canal  to  such 
a  degree  that  the  passage  of  a  viable  foetus  is  impossible.  The 
principal  causes  of  such  narrowing  are  contracted  pelvis,  bony 
or  malignant  tumours  blocking  the  pelvis,  and  extreme  cicatrisa- 
tion of  the  vagina  or  cervix.  This  group  was  in  the  past  a  usual 
indication  for  the  induction  of  abortion,  but  now,  owing  to  the 
improved  technique  of  Csesarean  section,  it  is  seldom  regarded 
as  an  indication. 

Instruments. — If  the  cervix  is  to  be  dilated  and  the  ovum 
removed,  the  following  instruments  are  required  : — a  posterior 
speculum,  two  American  forceps,  sea-tangle  tents,  Hegar's 
dilators,  Bozemann's  catheter,  and  a  flushing  curette.  If  labour 
is  to  be  induced,  a  couple  of  sterile  gum-elastic  bougies  are. 
required. 

Operation. — If  the  operation  has  to  be  performed  prior  to  the 
formation  of  the  placenta,  i.e.,  before  the  fourth  month,  the 
simplest  method  consists  in  dilating  the  cervix  and  removing  the 
ovum  with  the  finger.  In  order  to  do  this,  preliminary  dilata- 
tion of  the  cervix  must  be  effected  by  the  introduction  of  sea- 
tangle  tents  for  twenty-four  or  forty-eight  hours,  then  dilatation 
completed,  by  means  of  Hegar's  dilators,  up  to  the  size  necessary 
to  admit  two  fingers,  and  then  the  finger  introduced  and  the  ovum 
detached  and  expressed.  If  any  fragments  are  left  behind,  the 
uterus  may  be  gently  curetted  with  a  flushing  curette. 

If  the  operation  has  to  be  performed  after  the  formation  of  the 
placenta,  but  while  the  ovum  is  still  small,  i.e.,  from  the  fourth 
to  the  sixth  month,  the  best  and  safest  method  consists  in 
puncturing  the  membranes  with  a  stylette  after  a  slight  degree 
of  initial  dilatation  of  the  cervix  with  Hegar's  dilators.  The 
liquor  amnii  will  then  escape,  and  this  will  be  sufficient  to 
provoke  the  onset  of  labour.  After  the  sixth  month,  abortion 
will  be  best  induced  by  Krause's  method,  as  in  the  case  of  prema- 
ture labour. 


968  OBSTETRICAL  OPERATIONS 


THE  INDUCTION  OF  PREMATURE  LABOUR 

The  induction  of  labour  is  the  term  applied  to  the  bringing  on 
of  labour  after  the  foetus  has  become  viable,  but  before  full  term. 
A  foetus  is  said  to  be  viable  after  the  twenty-eighth  week,  but 
in  practice  a  foetus  of  less  than  thirty  weeks  is  so  difficult  to  rear 
that  it  can  scarcely  be  considered  to  be  viable.  Consequently,  as 
the  induction  of  premature  labour  is  usually  performed  in  order  to 
save  the  life  of  the  foetus,  it  is  not  as  a  rule  performed  before  the 
latter  date. 

Indications. — The  following  are  the  chief  indications  for  the 
induction  of  premature  labour  : — 

(i)  Certain  degrees  of  contracted  pelvis. 

(2)  The  habitual  death  of  the  foetus  at  a  period  after  it  has 
become  viable,  save  in  cases  due  to  syphilis  or  renal  disease. 

(3)  Certain  diseases  of  or  accompanying  pregnancy,  which 
threaten  the  life  of  the  mother,  as  renal,  cardiac,  or  pulmonary 
diseases ;  certain  cases  of  eclampsia,  or  undue  interference  with 
the  action  of  the  heart  and  lungs  owing  to  the  excessive  size  of 
the  uterus,  as  in  hydramnios. 

We  have  already  discussed  the  value  of  the  induction  of  labour 
in  contracted  pelvis,  and  need  not  again  refer  to  it  save  to  say 
that  the  induction  of  premature  labour  is  usually  indicated  in 
cases  of  flat  pelvis  in  which  the  true  conjugate  measures  between 
2f  and  3J  inches,  and  in  generally  contracted  pelvis  in  which  it 
measures  between  3  and  3f  inches.  In  these  countries,  we  think 
most  obstetricians  are  agreed  as  to  the  value  of  premature  labour 
in  such  cases,  but  the  fact  cannot  be  overlooked  that  in  other 
countries  many  of  the  highest  authorities  consider  that  the 
interests  of  the  foetus  demand  the  adoption  of  other  measures. 
Thus  Sanger,  Bar,  and  Whitridge  Williams  advise  Caesarean 
section  at  term  as  an  alternative  to  the  induction  of  labour  in 
all  possible  cases,  while  Pinard  believes  symphysiotomy  to  be 
preferable.  Undoubtedly,  the  foetal  mortality  is  high  after  the 
induction  of  premature  labour,  and  there  is  a  very  perceptible 
maternal  mortality  the  result  of  infection,  while  in  competent 
hands  the  maternal  mortality  of  Caesarean  section  and  sym- 
physiotomy is  very  low.  Still,  in  general  practice,  the  induction 
of  labour  possesses  great  and  obvious  advantages,  and  is,  we 
consider,  the  proper  course  to  adopt  in  suitable  cases.  If,  how- 
ever, it  fails  to  save  the  life  of  the  foetus  in  any  patient,  it  is  but 
right  that,  at  a  subsequent  pregnancy,  the  advisability  of  the 
adoption  of  other  measures  should  be  fully  considered. 

Methods. — The  different  methods  that  have  been  suggested  from 
time  to  time  of  inducing  premature  labour  are  numerous.  Some 
are    certain    but   dangerous,  others   are   comparatively  safe  but 


THE  INDUCTION  OF  PREMATURE  LABOUR  969 

uncertain,  others  still  are  both  unsafe  and  uncertain,  whilst  the 
number  that  are  both  comparatively  safe  and  certain  is  not  very 
great,  and  there  is  no  method  that  can  be  regarded  as  entirely  free 
from  risk.  Further,  there  is  no  method  that  is  suitable  for  use  in 
all  cases.  The  following  is  a  brief  description  of  the  methods 
most  usually  adopted  : — 

Krause's  Method. — Krause's  method  of  catheterisation  of  the 
uterus  consists  in  the  passage  of  one  or  more  stout  gum-elastic 
bougies  or  catheters  between  the  membranes  and  the  uterine  wall. 
It  is  the  method  usually  adopted  in  cases  in  which  the  sole  indica- 
tion for  treatment  is  to  bring  on  labour  pains,  and  in  which  there 
is  no  necessity  for  haste.  If  carried  out  with  strict  attention  to 
asepsis,  it  is  comparatively  safe,  and,  if  a  sufficient  number  of 
bougies  are  introduced,  it  is  tolerably  certain.  Bougies  are  pre- 
ferable to  catheters,  as  it  is  easier  to  sterilise  them.  The  opera- 
tion is  performed  as  follows  : — The  patient  is  placed  in  the  dorsal 
cross-bed  position,  the  vagina  douched,  a  posterior  speculum 
introduced,  and  the  cervix  caught  and  drawn  down  with  an 
American  forceps.  The  plug  of  mucus,  which  is  sometimes 
infected,  should  be  removed  from  the  cervical  canal  by  means 
of  a  piece  of  cotton-wool  twisted  round  a  probe,  in  order  that 
it  may  not  be  carried  upwards  into  the  uterus.  Three  or  four 
gum-elastic  bougies,  which  have  been  sterilised  by  boiling  for 
ten  minutes,  or  by  prolonged  soaking  in  a  1  in  500  solution  of 
corrosive  sublimate,  are  then  passed  one  after  another  through 
the  internal  os,  and  upwards  so  far  as  they  will  go  between  the 
membranes  and  the  uterine  wall,  without  using  any  undue  force. 
If  a  bougie  meets  with  much  resistance  when  passed  in  one 
direction,  it  must  be  withdrawn  and  passed  in  another  direction, 
as  such  resistance  is  probably  caused  by  the  placenta,  and,  if  the 
latter  is  wounded,  haemorrhage  may  follow.  The  bougies  should 
not  lie  too  close  together,  as  what  is  desired  is  to  bring  about  a 
considerable  degree  of  separation  of  the  membranes.  Every  care 
should  be  taken  to  avoid  rupturing  the  membranes,  as  if  this 
occurs  it  is  a  distinct  misfortune.  In  some  cases,  however,  it  is 
practically  unavoidable,  owing  to  their  extreme  thinness.  As 
soon  as  the  bougies  are  in  position,  a  piece  of  iodoform  gauze  is 
wrapped  round  their  vaginal  ends,  to  prevent  them  from  pressing 
against  the  vaginal  mucous  membrane,  and  the  patient  is  kept 
quietly  in  bed.  The  time  at  which  labour  comes  on  after  the 
introduction  of  the  bougies  is  very  variable.  It  may  occur  in  a 
few  hours,  or  it  may  not  occur  for  several  days,  and  only  then 
when  other  ancillary  measures  are  adopted.  If  labour  follows 
within  twenty-four  hours,  the  bougies  are  removed  as  soon  as  the 
contractions  are  occurring  regularly  and  strongly.  If  labour  does 
not  occur  within  that  time,  the  bougies  must  be  removed,  the 
vagina  well  douched,  and  a  fresh  set  introduced.  If  three  sets 
are  introduced  without  result,  some  other  method  must  be 
adopted,  and  in  such  cases  the  best  course  is  to  dilate  the  cervix 


970  OBSTETRICAL  OPERATIONS 

with  hydrostatic  or  other  dilators,  and  if  labour  pains  still  do  not 
occur,  to  turn  the  foetus  and  draw  down  a  leg  into  the  vagina. 

Podalic  Version,  and  Rupture  of  the  Membranes. — In  order  to 
carry  out  this  method  of  inducing  labour,  a  sufficient  degree  of 
dilatation  of  the  cervix  to  admit  at  least  two  fingers  must  be 
present.  This  degree  is  usually  present  in  cases  of  ante-partum 
haemorrhage,  in  which  this  method  of  inducing  labour  is 
particularly  valuable,  but  in  other  cases,  if  podalic  version  is  to  be 
adopted,  a  preliminary  dilatation  of  the  cervix  with  hydrostatic 
or  other  dilators  is  necessary.  With  the  exception  of  cases  of 
placenta  praevia,  this  method  is  only  adopted  in  cases  in  which 
Krause's  method  has  failed.  Version  in  these  cases  is  per- 
formed by  the  bipolar  method,  and  as  soon  as  a  foot  has  been 
brought  over  the  os  internum,  the  membranes  are  ruptured  and 
the  foot  drawn  down  into  the  vagina.  If,  as  sometimes  happens, 
uterine  contractions  do  not  result,  they  may  be  excited  by  gentle 
and  continuous  traction  applied  to  the  foot  in  the  vagina. 

Tamponade  of  the  Vagina. — Tamponade  of  the  vagina,  if  so 
performed  as  to  cause  firm  pressure  against  the  cervix  and  lower 
part  of  the  uterus,  will  as  a  rule  bring  on  uterine  contractions.  It 
is  the  method  usually  adopted  in  cases  of  accidental  haemorrhage, 
as  it  at  once  checks  the  haemorrhage  and  brings  on  labour. 
Williams  *  advises  that,  as  well  as  plugging  the  vagina,  the  cervix 
be  also  tightly  plugged,  and  this  step  is  probably  of  advantage. 
Some  of  the  gauze  may  also  be  passed  through  the  os  internum 
in  such  a  manner  as  to  press  upon  and  detach  the  membranes 
covering  the  lower  pole  of  the  ovum.  Spineli  recommended  that 
the  portion  of  gauze  passed  into  the  uterus  should  be  soaked  in 
ichthyol -glycerine.  We  do  not  know  that  any  particular 
advantage  is  attached  to  the  use  of  ichthyol,  but  as  glycerine  is  a 
direct  exciter  of  contraction  in  unstriped  muscle,  its  use  ought  to 
prove  of  value. 

Intra-uterine  Injections. — Cohen  recommended  some  years  ago 
the  injection  of  fluid  between  the  membranes  and  the  uterine  wall 
as  a  certain  means  of  inducing  labour.  He  advised  the  use  of 
aqua  picis  in  quantities  of  from  200  to  300  c.cs.  (7  to  10  oz.).  More 
recently  Pelzer  t  suggested  the  use  instead  of  sterile  glycerine,  in 
quantities  of  100  c.cs.  (3^  oz.).  Pelzer  claimed  that  glycerine 
acted  in  three  ways  : — that  it  caused  a  mechanical  separation  of 
the  membranes  ;  that  it  directly  stimulated  the  uterine  fibres  to 
contract ;  and  that  by  its  hygroscopic  properties  it  drew  liquor 
amnii  through  the  membranes,  and  so  rendered  them  flaccid. 
There  is  no  doubt  that  the  injection  of  glycerine  quickly  causes 
the  onset  of  uterine  contractions,  but  unfortunately  its  use  is 
far  from  safe,  as,  if  used  in  these  quantities  and  in  a  manner 
which    apparently  permits   of   its    rapid   absorption   unchanged, 

*  Op.  cit.,  p.  346. 

f  '  Uber  einleitung  der  kiinstlichen  Friihgeburt,'  Cent.  f.  Gy'tt.,  1892, 
PP-  35.  36. 


THE  INDUCTION  OF  PREMATURE  LABOUR  971 

glycerine  can  cause  very  severe  toxic  symptoms,  and  even  death. 
Pfannelstiel*  called  attention  to  this  danger  in  1894,  and  since 
then  other  writers  have  also  done  so.  To  meet  this  objection, 
Kossman  used  very  much  smaller  quantities  of  glycerine,  and 
successfully  induced  labour  by  injecting  5  c.cs.  (85  minims)  of 
glycerine.  He  considered  that  it  was  quite  unnecessary  to  use 
glycerine  in  large  quantities  for  hygroscopic  purposes,  and  that 
the  injection  of  small  quantities  with  the  object  of  stimulating  the 
muscle  fibres,  as  in  the  rectum,  was  sufficient.  His  results  were 
satisfactory,  so  far  as  they  went,  but  in  spite  of  the  fact  that  a 
safe,  certain,  and  fairly  quick  means  of  inducing  labour  is  required, 
they  have  not  been  generally  accepted,  and  further  evidence  on 
the  use  of  glycerine  is  still  required. 

Dilatation  of  the  Cervix. — Dilatation  of  the  cervix  is  not  often 
used  alone  as  a  means  of  inducing  labour,  but  rather  as  an 
adjunct  to  other  methods.  It  is  usually  adopted  when  cathe- 
terisation  of  the  uterus  fails  to  induce  contractions.  The  different 
means  of  effecting  dilatation  have  been  described  already. 

Rupture  of  the  Membranes. — This  method,  which  was  intro- 
duced by  Scheel,  is  the  simplest  and  the  most  obvious  way 
of  inducing  labour,  as  it  is  so  easily  performed.  Unfortunately, 
however,  it  is  not  satisfactory  on  account  of  its  prejudicial  effect 
on  the  mechanism  of  labour,  and  also  because  the  interval 
between  the  rupture  of  the  membranes  and  the  start  of  contrac- 
tions is  very  variable.  Consequently,  its  use  is  limited  to  cases  in 
which  we  desire  to  allow  some  of  the  liquor  amnii  to  escape,  as 
in  cases  in  which  labour  has  to  be  induced  in  consequence  of 
threatened  cardiac  failure  due  to  the  pressure  of  a  very  large 
uterus. 

There  are  numerous  other  methods  of  inducing  labour  which 
have  been  recommended  from  time  to  time,  but  we  do  not 
consider  that  they  are  of  sufficient  importance  to  be  described. 
Amongst  them  are  the  following  : 

(1)  Prolonged  vaginal  douching — Kiwisch's  method.  This  is 
tedious  and  uncertain. 

(2)  The  use  of  electricity.  This  is  most  uncertain,  and  neces- 
sitates the  employment  of  apparatus  which  is  seldom  at  the 
disposal  of  the  obstetrician. 

(3)  The  use  of  so-called  ecbolics.  It  is  now  generally  recog- 
nised that  there  is  no  drug  that  will  bring  on  labour  unless  it  is 
administered  in  toxic  doses.  Consequently,  this  method  is  not 
of  practical  value. 

*  '  Uber  die  Gefahrlichkeit  der  intraut.  Glycerineinspritzung,'  Centraibl. 
f.  Gyn.,  1894,  v°l-  xxix. ,  pp.  37-49. 


972  OBSTETRICAL  OPERATIONS 


THE  MANUAL  REMOVAL  OF  THE  PLACENTA 

The  manual  removal  of  the  placenta  has  been  already  described 
in  the  sections  dealing  with  retention  of  the  placenta  (v.  Part  VII. , 
Chap.  IX.). 


THE  SUTURE  OF  CERVICAL  LACERATIONS 

The  necessity  for  suturing  cervical  lacerations  does  not  often 
arise,  since  even  if  a  laceration  is  present,  it  is  not  detected 
unless  it  gives  rise  to  haemorrhage.  The  practice,  which  has  been 
occasionally  recommended,  of  examining  the  cervix  in  all  cases 
immediately  after  the  expulsion  of  the  placenta,  with  the  object 
of  determining  the  presence  of  cervical  lacerations,  is  objectionable 
in  the  highest  degree  on  account  of  the  unnecessary  manipulations 
it  entails  and  the  attendant  risk  of  infecting  the  genital  tract. 
Besides,  the  difficulty  of  detecting  the  presence  of  a  laceration  is 
considerable,  and  the  difficulty  of  determining  whether  the  lacera- 
tion requires  suturing  is  even  greater.  Many  lacerations  which 
to  the  examining  finger  appear  to  be  of  large  size,  will  subse- 
quently almost  entirely  disappear  in  consequence  of  uterine 
involution.  We  consider  that  far  more  benefit  will  result  to  the 
patient  from  the  adoption  of  a  routine  examination  made  from  a 
fortnight  to  three  weeks  after  delivery,  than  from  an  examination 
made  immediately  after  delivery. 

Indications. — Suture  of  cervical  lacerations  is  indicated  in  cases 
of  traumatic  haemorrhage  from  the  cervix. 

Instruments.  —  The  following  instruments  are  required  :  —  a 
needle  -  holder,  small  curved  needles,  silk,  silk  -  worm  gut,  or 
catgut.  It  is,  however,  more  easy  to  suture  the  laceration  if 
there  are  also  at  hand  a  large  posterior  speculum  and  a  couple  of 
American  forceps  ;  in  practice,  however,  we  usually  have  to  work 
without  them. 

Operation. — If  all  the  necessary  instruments  are  at  hand,  a 
posterior  speculum  is  introduced,  the  cervix  exposed,  and  the 
laceration  found  and  drawn  into  view  by  two  American  forceps, 
one  applied  to  each  edge.  If,  however,  as  frequently  happens,  we 
have  neither  a  speculum  nor  volsella,  an  extemporised  form  of 
cervical  tractor  can  be  made  in  the  following  manner  : — Thread  a 
small  curved  needle  with  a  long  ligature  of  number  eight  or  ten 
silk.  Pass  two  fingers  of  the  left  hand  into  the  vagina  to  touch  the 
most  prominent  portion  or  the  cervix.  Introduce  the  needle — 
held  in  a  needle-holder — into  the  vagina  under  cover  of  the  fingers 
of  the  left  hand,  and  pass  it  through  the  cervix.  The  ends  of  the 
ligature  are  then  knotted  together,  and  by  traction  upon  them  the 
cervix  can  be  exposed.     The  descent  of  the  cervix  will  be  very 


SUTURE  OF  PERINMAL  AND  VAGINAL  LACERATIONS     973 

much  facilitated  by  firm  suprapubic  pressure  upon  the  fundus. 
As  soon  as  the  source  of  the  haemorrhage  has  been  exposed, 
either  the  bleeding  vessel  is  tied  or  the  laceration  sutured.  In 
the  latter  case,  the  sutures  are  passed  at  right  angles  to  the  tear. 
If  the  site  of  the  haemorrhage  cannot  be  found,  the  bleeding  can  be 
stopped  by  plugging  the  utero-vaginal  canal  with  iodoform  gauze. 
Cervical  sutures  inserted  with  the  object  of  checking  haemorrhage 
may  be  removed  on  the  eighth  day.  If,  however,  they  were 
inserted  with  the  object  of  bringing  together  the  edges  of  a 
laceration,  they  may  be  left  in  situ  until  the  fourteenth  day. 

THE  SUTURE  OF  PERINEAL  AND  VAGINAL 
LACERATIONS 

The  suture  of  perinaeal  lacerations  is  the  most  common  opera- 
tion in  obstetrical  practice,  and  on  its  proper  performance  the 
patient's  subsequent  comfort  and  well  -  being  greatly  depends. 
The  worst  perinaeal  laceration,  if  kept  aseptic  and  properly 
sutured,  can  be  healed  completely  and  the  perinaeum  restored  to 
its  former  condition  ;  while,  if  it  is  left  unsutured,  it  will  not 
improbably  form  the  first  step  in  the  subsequent  occurrence  of 
chronic  uterine  displacements. 

Indications.  —  Suture  of  a  perinaeal  or  vaginal  laceration  is 
necessary  in  all  cases  in  which  the  tear  extends  beyond  the 
posterior  commissure. 

Instruments.  —  The  instruments  required  are  as  follows  :  —  a 
needle-holder ;  large  and  medium-sized  whole  curved  needles ; 
silk,  silkworm-gut,  or-  catgut.  In  the  case  of  extensive  lacera- 
tion of  the  vaginal  mucous  membrane,  a  large  posterior  vaginal 
speculum  is  of  use,  as  it  can  be  used  as  an  anterior  speculum  and 
made  to  expose  the  posterior  vaginal  wall  by  drawing  the  anterior 
wall  forwards. 

Operations. — The  perinaeum  may  be  sutured  at  any  time  after  the 
birth  of  the  infant.  Suturing  during  the  third  stage,  i.e.,  before 
the  placenta  comes  away,  offers  the  advantage  that  at  this  time 
the  patient  is  usually  still  under  the  influence  of  the  anaesthetic 
she  has  had  during  the  stage  of  expulsion,  and  even  if  she  has 
become  conscious,  the  perinaeal  and  vaginal  tissues  are  tempor- 
arily analgesic  in  consequence  of  the  bruising  to  which  they  have 
been  subjected.  Suture  before  the  expulsion  of  the  placenta, 
however,  possesses  the  disadvantage  that,  if  the  placenta  is 
adherent  and  has  to  be  removed  subsequently,  the  introduction 
of  the  hand  may  necessitate  the  removal  and  re-insertion  of  the 
sutures,  as,  if  they  are  not  removed,  the  tissues  may  again  tear 
apart.  In  the  case  of  slight  lacerations,  however,  in  which  the 
perinaeum  alone  is  involved,  and  especially  in  the  case  of  those 
occurring  in  primiparae,  in  whom  placental  retention  is  unlikely  to 
occur,  suture  may  be  performed  during  the  third  stage.     On  the 


974 


OBSTETRICAL  OPERATIONS 


other  hand,  the  suturing  may  be  performed  immediately  after 
the  expulsion  of  the  placenta.  If  there  is  any  reason  to  fear 
placental  retention,  or  if  extensive  laceration  of  the  vaginal  walls 
necessitates  the  introduction  of  intravaginal  sutures,  it  is  better 
to  postpone  the  suture  until  this  period,  although  it  may  be 
necessary  to  again  place  the  patient  under  the  influence  of  an 
anaesthetic. 

When  the  confinement  occurs  at  night,  the  suturing  may  be 
postponed  with  advantage  until  the  following  morning,  in  order 
that  it  may  be  done  with  more  deliberation,  and  in  better  light. 


Fig.  400.— Perineal  and  Vaginal  Lacerations.     A,  Simple  Laceration 

of    Perineal    Body;    B,    Perineal    Laceration    and    Unilateral 

Vaginal  Laceration. 
P,  Extent  of  perinseal  laceration;  C,   C\  posterior  commissure;    L,  upper 

limit   of  vaginal   laceration ;  PV,  posterior  vaginal  wall ;  AV,  anterior 

vaginal  wall.     (Bumm.) 

This  is  an  unnecessary  course  to  adopt  in  the  case  of  small 
lacerations,  but  in  the  case  of  extensive  lacerations,  particularly 
when  they  involve  the  rectal  wall,  it  is  undoubtedly  the  proper 
course,  as  it  offers  the  best  prospect  of  obtaining  a  good  result. 
It  is  often  most  difficult  to  suture  a  complicated  laceration  m 
the  proper  manner  when  the  attempt  is  made  immediately  after 
delivery,  as  the  bad  light  and  the  obscuring  of  the  wound  by  the 
blood  which  comes  from  the  uterus  render  it  difficult  to  bring 
the  torn  surfaces  into  correct  coaptation. 


SUTURE  OF  PERINJEAL  AND   VAGINAL  LACERATIONS 


975 


As  we  have  already  seen,  perinatal  lacerations  can  be  divided 
into  two  classes :  —  Complete  lacerations,  in  which  the  tear 
extends  through  the  rectal  wall ;  and  incomplete  lacerations,  in 
which  the  tear  involves  the  perinaeal  body,  the  rectal  wall  re- 
maining intact.  Either  of  these  classes  may  be  further  com- 
plicated by  the  presence  of  deep  laceration  of  the  posterior 
vaginal  wall,  as  shown  in  Figs.  400  and  401.  It  may,  however,  be 
more  convenient  for  our  present  purpose  if,  instead  of  the  fore- 
going classification,  we  classify  lacerations  as  follows  : — 


A  B 

Fig.  401. — Perineal  and  Vaginal  Lacerations.  A,  Laceration  of 
Perineum  and  Bilateral  Laceration  of  Vagina  ;  B,  Laceration 
of  Perin.eum,  Rectal  Wall,  and  Vaginal  Wall. 

R,  Rectal  laceration;  An,  anus;  P,  extent  of  perinaeal  laceration;  P',  pos- 
terior limit  of  laceration;  C,  C,  posterior  commissure;  L,  L',  upper 
limits  of  vaginal  laceration ;  PV,  posterior  vaginal  wall ;  AV,  anterior 
vaginal  wall.     (Bumm.) 

(1)  Laceration  of  the  perinaeal  body  alone. 

(2)  Laceration  of  the  perinaeal  body  and  (a)  ot  the  rectal  wall, 
(b)  of  the  vaginal  wall,  (c)  of  both  rectal  and  vaginal  walls. 

If  the  perinaeal  body  alone  is  torn,  the  operation  of  suturing  is 
an  easy  one,  and  can  be  performed  with  the  patient  in  either  the 
dorsal  or  the  lateral  position.  The  nature  of  the  laceration  is 
usually  as  shown  in  Fig.  400,  A,  and  the  object  of  the  sutures  is  to 
bring  the  points  C  and  C  and  the  raw  surfaces  posterior  to  them 
into  contact  (v.  Fig.  402).     With  this  object,  two  or  more  sutures, 


976 


OBSTETRICAL  OPERATIONS 


according   to  the  length  of  the    tear,  are  inserted  through  the 
perinaeal  skin  at  one  edge  of  the  laceration,  and  passed  upwards 


Fig.  402. — The  Suture  of  a  Laceration  of  the  Perineum  and  Vagina. 
The  vaginal  sutures  are  tied  ;  the  perinaeal  sutures  are  in  position.      (Bumm.) 

beneath  the  torn  surface,  on  a  plane  parallel  to  the  rectum,  to 
emerge   at  a  corresponding    point   on   the  perinatal  skin  at  the 


Fig.  403. — The  Suture  of  a  Complete  Laceration  of  the  Perineum. 
The  sutures  in  position  in  the  rectal  wall.     (Bumm.) 

opposite  edge  of  the  laceration.      The   sutures    pass   completely 
beneath  the  laceration,  and,  when  tied,  bring  the  points  C  and  C 


THE  SUTURE  OF  PERINEAL  LACERATIONS 


977 


and  the  edges  CP  and  C'P  together.  The  sutures  may  be  of 
silk,  silkworm  gut,  or  catgut.  Silkworm  gut  is  perhaps  best  on 
account  of  the  absence  of  capillarity  ;  but  catgut  is  most  con- 
venient, as  it  does  not  require  to  be  subsequently  removed. 

If  in  addition  to  the  perinaeal  tear,  there  is  a  laceration  of  the 


Fig.  404. — The  Suture  of  a  Complete  Laceration  of  the  Perineum. 

The  sutures  in  the  rectal  and  vaginal  walls  have  been  tied.     The 
perinasal  sutures  are  not  yet  inserted.     (Bumm.) 


posterior  vaginal  wall  extending  upwards  in  the  middle  line,  or 
to  one  side,  as  shown  in  Fig.  400,  or  at  both  sides,  as  shown  in 
Fig.  401,  before  inserting  the  perinaeal  sutures,  the  edges  of  the 
vaginal  tear  must  be  brought  together.  To  do  this  satisfactorily, 
the  posterior  wall  must  be  exposed.  If  we  have  a  suitable 
speculum  at  hand,  it  is  introduced  as  an  anterior  speculum,  and 
draws  up  the  anterior  wall.  If  we  have  no  speculum,  a  sufficient 
degree  of  exposure  can  usually  be  obtained  by  taking  a  large  plug 
of  cotton-wool,  which  has  been  sterilised  by  prolonged  immersion 
in  an  antiseptic — in  default  of  steam  sterilisation — and  passing 
it  into  the  vagina  above  the  upper  limits  of  the  tear.  This,  if  of 
sufficient  size,  will  answer  the  double  purpose  of  keeping  back  the 
anterior  wall,  and  also  of  temporarily   damming   up  the   blood 

62 


978  OBSTETRICAL  OPERATIONS 

flowing  down  from  the  uterus  and  so  preventing  it  from  obscuring 
the  field  of  operation.  The  laceration  being  thus  exposed,  a 
small  curved  needle  threaded  with  catgut  is  taken,  and  the  edges 
of  the  vaginal  mucous  membrane  of  each  rent  are  in  turn  brought 
together  from  above  downwards.  The  sutures  may  be  interrupted, 
as  shown  in  the  drawing,  or  continuous,  the  latter  being  more 
easily  and  quickly  inserted.  This  being  done,  the  condition  is 
now  one  of  simple  laceration  of  the  perinatal  body,  and  this  is 
sutured  as  already  described. 

If,  on  the  other  hand,  the  perinaeal  tear  is  complicated  by  an 
accompanying  tear  of  the  rectal  wall,  either  with  or  without  an 
extensive  tear  of  the  vaginal  wall,  the  first  step  of  the  operation 
consists  in  bringing  together  the  edges  of  the  torn  rectal  wall. 
This  is  best  done  by  a  continuous  suture  passed  as  shown  in  the 
drawing,  and  commencing  above.  The  suture  is  introduced  from 
the  anterior  aspect  of  the  rectal  wall,  and  traverses  the  thickness 
of  the  wall  with  the  exception  of  the  mucous  coat  (v.  Fig.  402). 
If  it  is  thought  better,  the  sutures  may  be  interrupted.  These 
sutures  must  be  of  catgut,  as  they  will  be  subsequently  buried 
when  the  perinaeal  sutures  are  tied.  If  a  vaginal  rent  also  is 
present,  it  is  next  sutured  from  the  vagina  as  has  been  described 
(v.  Fig.  403),  and,  finally,  the  perinaeal  tear  is  closed  by  sutures 
passed  from  the  skin  (v.  Fig.  401). 

After-treatment. — The  after-treatment  consists  in  maintaining 
asepsis,  and  in  keeping  the  patient  quiet.  The  perinaeal  wound 
should  be  washed  with  a  mild  antiseptic  lotion  two  or  three  times 
a  day,  and  should  be  kept  as  dry  as  possible.  If  the  lochia  are 
fcetid  the  vagina  should  be  douched  daily,  but  so  long  as  they 
are  healthy  no  douching  is  required.  The  patient  ought  not  to  be 
allowed  to  sit  up  in  bed  before  the  tenth  day.  It  is  advisable 
to  give  a  purgative  on  the  evening  of  the  second  day,  in  order  to 
prevent  the  accumulation  of  faeces  in  the  rectum.  If  the  sutures 
used  are  non-absorbable,  they  must  be  removed  on  the  seventh 
day. 


TAMPONADE  OF  THE  GENITAL  TRACT 

Tamponade,  or  plugging,  of  the  genital  tract  is  a  procedure  of 
considerable  value  in  obstetrical  practice,  inasmuch  as  it  affords 
a  means  of  compressing  bleeding  areas,  and  so  checking  haemor- 
rhage ;  of  stimulating  uterine  contractions,  and  so  inducing 
labour  ;  and  of  bringing  an  antiseptic  into  contact  with  infected 
areas. 

Indications. — The  vaginal  tampon  is  indicated  before  delivery 
in  certain  cases  of  accidental  haemorrhage ;  it  is  never  indicated 
subsequent  to  delivery  save  in  association  with  a  uterine  tampon. 
The  uterine  or  the  utero-vaginal  tampon  is  indicated  in  certain 
cases  of  severe  post-partum  haemorrhage,  in  cases  of  lochio-metra 


TAMPONADE  OF  THE  GENITAL  TRACT 


979 


(retention  of  the  lochia  in  the  uterine  cavity),  in  septic  or  putrid 
endometritis,  and  in  certain  cases  of  threatened  abortion. 

Instruments. — The  material  usually  adopted  for  plugging  the 
uterus_  is  iodoform  gauze,  but  for  plugging  the  vagina  in  cases 
of  accidental  haemorrhage  cotton-wool  is  perhaps  more  suitable, 
as  it  is  possible  to  introduce  a  larger  quantity  of  it,  and  so  to 
more  effectually  seal  the  uterine  orifice.  For  tamponing  the 
vagina,  a  posterior  speculum  is  the  only  instrument  required, 
and  it  can  be  dispensed  with.  For  uterine  plugging,  a  posterior 
speculum  is  necessary,  especially  in  cases  of  threatened  abortion. 
After  delivery,  it  can  be  more  easily  dispensed  with,  but,  if  at 
hand,  it  is  of  considerable  assistance.  Two  American  forceps  or 
other  form  of  volsellum  are  also  required  for  fixing  the  cervix, 
and  a  plugging  forceps,  a  Bozemann's  catheter,  or  a  uterine 
sound  for  introducing  the  gauze. 

Operation. — The  operation  of  plugging  the  vagina  in  cases  of 
ante-partum  haemorrhage  is  performed  as  follows  : — Place  the 
patient  in  the  cross-bed  position,  with  her  hips  well  over  the  edge 
of  the  bed.     Administer  an  anaesthetic  if  necessary,  as  is  usually 


'3  b  CALE 
Fig.  405. — Forceps  for  Plugging  the  Uterus. 


the  case,  since  the  firm  application  of  a  plug  is  rather  a  painful 
procedure.  Wash  the  external  genitals  and  douche  out  the  vagina 
thoroughly.  Then,  pass  a  posterior  speculum,  and,  with  strips 
of  iodoform  gauze  soaked  in  lysol  solution  (0-5  per  cent.), 
plug  tightly  round  the  cervix.  A  speculum  is  not  necessary, 
but,  if  the  patient  is  not  under  an  anaesthetic,  it  renders  the 
proceeding  less  painful  by  protecting  the  perinaeum.  The 
remainder  of  the  vagina  is  then  plugged  as  tightly  as  possible 
with  balls  of  cotton-wool  about  the  size  of  a  golf  ball,  which  have 
been  previously  sterilised  by  boiling  and  then  soaked  in  lysol 
solution.  This  plugging  is  continued  until  no  more  can  be 
pressed  into  the  vagina  (v.  Fig.  296).  The  patient  is  then  put 
back  to  bed,  and  a  binder  pinned  as  tightly  as  possible  round 
the  abdomen,  while  a  T-bandage  is  brought  down  between  the 
thighs,  and  also  fixed  firmly.  By  this  means,  the  uterus  is 
compressed  between  the  plug  in  the  vagina  and  the  abdominal 
binder,  and  the  intra  -  uterine  pressure  is  raised.  The  plug 
is  left  in  until  strong  labour  pains  ensue,  and  this  usually 
happens  in  from  two  to  four  hours.  In  some  cases  the  onset 
of  labour  is  slower  than    this,  and   in  such  the   plug  must  be 

62 — 2 


980 


OBSTETRICAL  OPERATIONS 


removed  in  twenty-four  hours  for  fear  of  decomposition  taking 
place.  If  haemorrhage  comes  on  again,  it  can  be  replaced,  but 
this  is  rarely  necessary. 

The  uterus  is  plugged  with  iodoform  gauze  in  the  following 
manner  : — Place  the  patient  in  the  cross-bed  position,  and  seize 
the  anterior  lip  of  the  cervix  with  one  American  forceps  and  the 
posterior  lip  with  another.  If  a  posterior  speculum  is  at  hand,  it 
may  be  introduced,  and  will  facilitate  the  proceeding.  It  is  not, 
however,  necessary.      Then,  pass  the  end  of  a  long  strip  of  iodo- 


jf. 


Sl'Ai. 


/ 


Fig.  406. — Tamponade  of  the  Uterus. 
C,  Anterior  lip  of  cervix  ;  O.,  uterine  orifice. 


form  gauze,  about  two  inches  in  width,  up  to  the  fundus,  by  means 
of  a  special  plugging  forceps  or  with  the  end  of  the  Bozemann's 
catheter.  The  remainder  of  the  strip  is  pushed  up  piece  by 
piece  until  it  is  finished.  A  fresh  strip  is  then  knotted  on  to  the 
former,  and  introduced  in  a  similar  manner.  As  soon  as  the 
uterus  is  full,  the  forceps  are  removed,  and  the  vagina  is  also 
plugged.  As  a  rule,  three  to  four  strips  of  gauze,  six  yards  long 
and  two  or  three  inches  wide,  are  required.  It  must  be  remembered 
that  it  is  not  the  large  cavity  of  a  dilated  uterus  which  we  have 


TAMPONADE  OF  THE  GENITAL  TRACT  981 

to  plug,  but  rather  the  comparatively  small  cavity  of  a  contract- 
ing one,  because  on  the  introduction  of  a  small  piece  of  gauze 
the  hitherto  flaccid  uterus  quickly  contracts  upon  the  foreign 
body.  Finally,  a  tight  abdominal  binder  is  applied  in  order  to 
compress  the  uterus  from  above,  and  ergot  may  be  given.  The 
gauze  must  be  removed  in  from  twelve  to  twenty-four  hours,  and 
if  there  is  any  rise  of  temperature  a  uterine  douche  ought  to  be 
administered. 


CHAPTER  II 
THE  APPLICATION  OF  THE  FOECEPS 

The  Introduction  of  the  Forceps— The  Modern  Forceps,  Tarnier's,  Milne 
Murray's,  Neville's — -The  Action  of  the  Forceps — Indications — The 
Mode  of  Application,  the  Pelvic  Method,  the  Cephalic  Method — The 
Application  of  the  Forceps  in  Presentations  other  than  the  Vertex ;  in 
Occipito-posterior  Positions  of  the  Head,  in  Face  Presentation,  in  Brow 
Presentation,  in  Pelvic  Presentation — Prognosis. 

In  the  majority  of  works  on  obstetrics  it  is  customary  to  devote 
a  considerable  amount  of  space  to  the  history  of  the  invention  of 
the  forceps,  and  to  a  description  of  many  of  the  hundreds  of 
patterns  which  have  been  devised  from  time  to  time  of  this 
instrument,  and  also  to  enter  with  considerable  minutiae  into  the 
discussion  of  the  various  moot  points  which  have  arisen  since 
its  introduction  some  three  hundred  years  ago.  We  do  not, 
however,  consider  that  such  a  discussion  is  very  profitable. 
Theories  with  regard  to  the  use  of  the  forceps  and  its  correct 
design  have  become  crystallised  by  experience  into  principles, 
and  these  principles,  though  subject  to  slight  modification,  accord- 
ing to  locality,  are  generally  recognised  by  obstetricians.  Accord- 
ingly, our  introduction  to  the  actual  description  and  use  of  the 
forceps  will  be  very  short. 

In,  or  about,  the  year  1600,  a  member  of  the  Chamberlen 
family — in  all  probability  Peter  Chamberlen  the  elder — devised 
the  prototype  of  the  modern  forceps.  He  and  his  successors 
kept  the  instrument  as  a  family  secret  for  a  number  of  years, 
until,  about  the  year  1730,  Hugh  Chamberlen  allowed  it  to  be 
divulged.  The  instrument  used  at  that  time  bore  a  rough 
resemblance  to  the  short  forceps  which  is  still  sometimes  seen. 
The  first  improvement  of  importance  was  made  when  Levret 
in  1747,  and  Smellie  in  1751,  working  independently,  added  a 
second  or  pelvic  curve,  and  at  the  same  time  increased  its 
length.  No  further  improvement  of  importance  was  made  until 
1877,  when  Tarnier  introduced  the  principle  of  axis-traction, 
which  has  done  so  much  to  improve  the  value  and  general  utility 
of  the  instrument.  So  far  as  the  British  forceps  is  concerned, 
obstetricians  are  indebted  to  Simpson  and  Barnes  for  the 
two    prevailing  types  of   instrument,   and  to  Neville  and  Milne 


THE  MODERN  FORCEPS  983 

Murray  for  the  application  to  the  latter  of  a  suitable  axis-traction 
apparatus. 

It  is  now  generally  recognised  that  a  suitable  forceps  must 
answer  to  the  following  description :  — It  must  be  made  com- 
pletely of  metal ;  it  must  be  a  '  long '  forceps,  possessing  a 
cephalic  and  a  pelvic  curve  ;  and  it  must  possess  an  axis-traction 
apparatus,  with  or  without  which  it  can  be  used.  Many  different 
patterns  of  the  forceps  fulfil  these  requirements,  but  the  three 
which  we  named  above,  Neville's,  Milne  Murray's,  and  Tarnier's, 
are  in  our  opinion  the  best  of  their  respective  classes. 

The  Modern  Forceps.  —  The  modern  forceps  consists  of  three 
parts:— a  left  or  lower  blade;  a  right  or  upper  blade;  and  an 
axis- traction  apparatus.  The  nature  of  the  blades  of  the  forceps 
can  be  best  learnt  from  the  accompanying  drawings.  As  will 
be  seen,  each  blade  possesses  two  curves — a  cephalic  curve  which 
enables  the  blade  to  adapt  itself  to  the  head  of  the  fcetus,  and  a 
pelvic  curve  which  enables  it  to  lie  in  the  curve  of  the  parturient 
canal.  The  blades  are  made  to  interlock  by  means  of  a  readily 
detachable  joint.  In  the  case  of  Tarnier's  forceps  the  joint  is 
what  is  known  as  a  French  joint,  in  the  case  of  Barnes'  or 
Simpson's  forceps  it  is  what  is  known  as  an  English  joint.  The 
latter  is  perhaps  the  better,  as  it  can  be  more  easily  and  quickly 
opened.  The  blades  cross  one  another  at  this  joint  in  scissors 
fashion.  When  the  blades  are  interlocked,  one  lies  below  the 
other,  and  consequently  it  is  termed  the  lower  blade,  and  its 
fellow  the  upper  blade.  Similarly,  when  the  forceps  is  in  position 
inside  the  pelvis,  one  blade  lies  at  the  left  side  of  the  pelvis,  and 
its  fellow  at  the  right  side.  The  former  consequently  is  known 
as  the  left  blade,  the  latter  as  the  right  blade.  If  the  forceps  are 
held  in  the  position  they  would  occupy  when  gripping  the  head, 
it  will  be  seen  that  the  left  blade  is  also  the  lower  blade,  while 
the  right  blade  is  the  upper  blade.  Students  are  often  confused 
between  the  two  blades,  and  many  devices  have  been  suggested 
for  enabling  them  to  easily  recognise  each.  The  easiest  way 
is  to  hold  each  blade  in  turn  as  it  would  lie  with  regard  to  an 
imaginary  patient — the  cephalic  curve  so  turned  that  it  can  catch 
the  head,  and  the  pelvic  curve  so  turned  that  it  will  be  adapted 
to  the  curve  of  the  pelvis.  The  side  to  which  the  blade  belongs 
will  then  be  obvious,  and  if  the  blades  are  crossed  with  the  right- 
hand  blade  uppermost,  they  will  readily  lock. 

The  exact  nature  of  the  axis-traction  apparatus  differs  according 
to  the  particular  type  of  instrument,  but,  speaking  in  general 
terms,  it  is  an  appliance  detachable  or  fixed,  which  is  fastened  to 
the  blade  either  just  below  the  fenestras  or  at  the  lock,  and  which 
enables  traction  to  be  made  on  the  forceps  in  a  line  directly  con- 
tinuous with  the  axis  of  the  fenestra,  i.e.,  of  that  portion  of  the 
blade  which  grips  the  head  of  the  fcetus.  At  the  same  time,  the 
traction  apparatus  is  so  jointed  that  the  forceps  is  free  to  rotate, 
and  to  follow  the  movements  of  the  descending  head  while  trac- 


984 


OBSTETRICAL  OPERATIONS 


tion  is  being  applied.  It  is  these  two  points — the  application  of 
the  traction  force  directly  in  the  line  of  the  axis  of  the  fenestra, 
and  the  freedom  of  the  forceps  to  follow  the  movements  of  the 
head — which  constitute  the  enormous  advantage  of  the  axis- 
traction  forceps.  When  the  head  of  the  foetus  is  either  being 
driven  or  being  pulled  through  the  pelvis,  it  has  to  follow  the 
curve  of  the  pelvis,  and  the  more  closely  the  line  of  direction  of 
the  force  which  is  acting  upon  it  corresponds  with  the  pelvic 
axis,  the  less  force  will  be  required  to  bring  the  head  through. 
If  the  line  of  force  does  not  correspond  with  the  pelvic  axis,  but  is 
partly  pushing,  or  pulling,  the  head  against  the  anterior,  lateral, 
or  posterior  wall  of  the  pelvis,  a  correspondingly  greater  degree 
of  force  is  required.  When  the  forceps  is  correctly  applied,  the 
axis  of  the  fenestra  of  the  blades  corresponds  with  sufficient  correct- 


Fig.  407. — Tarnier's  Diagram  showing  Defects  of  Ordinary  Forceps. 

AC,  Line  of  actual  traction;  AB,  direction  of  effective  co-efficient  of  force 
employed;  ADE,  direction  of  ineffective  co-efficient  wasted  against  the 
symphysis. 

ness  to  the  axis  of  that  part  of  the  parturient  curve  in  which  the 
head  is  at  the  time  situated,  and,  if  traction  can  be  applied  to  the 
forceps  in  the  axis  of  the  fenestra,  the  force  will  be  transmitted 
to  the  head  in  the  proper  manner.  It  is,  however,  at  once  evident 
that,  if  we  apply  traction  to  the  handles  of  the  ordinary  forceps 
without  any  axis-traction  apparatus,  we  shall  be  pulling  not  in 
the  axis  of  the  pelvis,  but  in  a  line  much  anterior  to  the  latter. 
This  is  clearly  shown  in  the  accompanying  diagram  (v.  Fig.  407). 
The  force  applied  to  the  handles  acts  along  the  line  AC,  and 
can  be  resolved  into  two  forces,  one  of  which,  AB,  acts  in  the 
required  direction — i.e.,  in  the  pelvic  axis,  while  the  other,  AE, 
acts  in  an  entirely  different  direction,  drags  the  head  against  the 


THE  AXIS-TRACTION  FORCEPS 


985 


back  of  the  symphysis,  and   consequently  is  a  retarding  rather 
than  an  accelerating  force. 

Various  devices  have  been  adopted  to  prevent  this  waste  of 
energy.  Forceps  have  been  made  with  a  third  or  perinaeal  curve 
with  the  object  of  bringing  the  handles  back  again  into  the  axis  of 
the  blades,  and  the  manoeuvre  known  as  Pajot's  was  introduced, 
by  means  of  which  the  tendency  to  pull  the  head  against  the 
symphysis  was  counteracted  (v.  Fig.  408).  None  of  these  devices 
is,  however,  satisfactory.  Traction  can  be  applied  in  the  correct 
direction  by  means  of  a  perinaeal  curve  on  the  forceps,  but  in 
such  a  forceps  the  second  great  desideratum  to  which  we  referred 
above  is  wanting,  i.e.,  the  freedom  of  the  forceps  to  follow  the 
movements  of  the  head.  In  the  modern  and  properly  con- 
structed axis-traction  forceps,  the  head  guides  the  forceps,  while 


Fig.  408. — Pajot's  Manceuvre.     (Williams.) 


in  any  pattern  of  forceps  without  an  axis-traction  apparatus  the 
forceps  guides  the  head.  The  same  objection  applies  to  Pajot's 
manceuvre,  with  this  added,  that  it  is  impossible  to  apply  by 
means  of  it  the  same  amount  of  force  in  the  required  direction 
that  can  be  applied  by  axis-traction. 

The  nature  of  the  axis-traction  apparatus  in  the  three  forms  of 
forceps  to  which  we  have  alluded  can  be  best  learnt  from  the 
drawings.  In  Tarnier's  and  Milne  Murray's,  there  are  two 
traction  rods  fastened  by  a  pivot  joint  to  the  blades  just  behind 
the  fenestrae,  while  in  Neville's  there  is  a  single  rod  which  is 
fastened  rigidly  to  the  forceps  at  the  handle  side  of  the  lock, 
the  same  fastening  serving  as  the  connecting  tie  between  the 
two  blades.  In  Tarnier's  and  Milne  Murray's  forceps,  the 
necessary  freedom  of  movement  is  obtained  by  the  pivotal 
attachment   of   the  rods,  by  the  power  of  free  rotation  of  the 


986  OBSTETRICAL  OPERATIONS 

traction  handle,  and  by  an  intermediate  joint.  In  Neville's 
forceps,  it  is  obtained  by  a  similar  power  of  rotation  of  the 
handle,  and  by  two  intermediate  joints  on  the  rod,  one  joint  per- 
mitting lateral,  the  other  vertical  movement.  In  Tarnier's  and 
Milne  Murray's  forceps  the  direction  in  which  traction  is  to  be 


J.I.      J.2.      (J 

Fig.  409. — Neville's  Axis-traction  Forceps. 

N,  Butterfly-nut  for  fixing  traction  rod  to  the  forceps  ;  J.i,  J. 2,  J. 3,  joints 
permitting — 1,  vertical  movement ;  2,  lateral  movement;  and  3,  rotation. 

applied  is  shown  by  the  relation  of  the  traction  rods  to  the 
handles  of  the  forceps,  the  rods  being  kept  close  to  the  handles 
without  touching  them.  In  Neville's  forceps,  there  is  on  the 
movable  part  of  the  traction  apparatus  an  arrow-head  indicator, 


Fig.  410. — Milne  Murray's  Axis-traction  Forceps. 


which  is  to  be  kept  in  opposition  to  the  pointed  end  of  the  rigid 
portion  of  the  traction  apparatus.  In  the  last  pattern  of  Milne 
Murray's  forceps,  the  position  of  the  traction  handle  can  be  so 
altered  that  the  line  of  traction  can  be  made  to  lie  in  front  of  or 
behind  the  axis  of  the  upper  half  of  the  blades.     Under  ordinary 


THE  AXIS-TRACTION  FORCEPS  987 

circumstances,  the  two  should  correspond,  but  Milne  Murray 
considered  that  in  certain  forms  of  pelvic  deformity  it  was  advis- 
able to  be  able  to  alter  their  relations. 

As  regards  the  relative  merits  of  the  different  patterns  of  the 
forceps,  those  who  are  accustomed  to  any  particular  pattern 
consider  that  pattern  the  best,  and  unless  they  find  one  which 
offers  a  manifest  improvement  are  unwilling  to  change.  We 
doubt  if  there  is  any  marked  advantage  possessed  by  one  of 
the  forms  which  we  have  referred  to  over  the  others.  We  our- 
selves are  accustomed  to  Neville's  forceps,  and  prefer  it.  It  has 
the  advantage  over  the  others  that  the  traction  apparatus  is  more 
simple,  and  that  it  is  only  fixed  to  the  forceps  after  the  blades 
have  been  applied  to  the  head.  In  the  other  forms,  the  traction 
rods  are  apt  to  give  trouble,  during  the  application  of  the  blades, 
to  anyone  not  perfectly  familiar  with  their  working.  The  objec- 
tion has  been  brought  against  Neville's  pattern  that,  because  the 
traction  rod  is  attached  to  the  handles  instead  of  to  the  blades,  it 


Fig.  411. — Tarnier's  Axis-traction  Forceps. 

is  not  a  true  axis-tractor.  We  do  not  profess  to  be  able  to  offer 
an  opinion  on  this  point,  but  the  question  was  referred  on  more 
than  one  occasion  to  a  distinguished  scientist — the  late  Professor 
G.  F.  Fitzgerald,  F.R.S.,  and  he  unhesitatingly  expressed  the 
opinion  that  the  point  of  attachment  of  the  rods  did  not  add  to 
or  take  from  the  qualities  of  an  instrument  as  an  axis-tractor 
provided  that  the  traction  was  applied  in  the  required  direction. 
In  Milne  Murray's  last  pattern  of  forceps,  it  appears  to  us 
that,  if  the  pivotal  attachment  of  the  rods  to  the  blades  was 
made  rigid,  and  the  horizontal  portions  of  the  rods  fastened 
rigidly  to  the  handles,  the  forceps  would  still  be  as  truly  an 
axis-traction  forceps  as  they  are  in  their  present  form,  provided 
the  joint  at  the  junction  of  the  traction  handle  to  the  vertical 
part  of  the  rods  was  sufficiently  free,  and  was  fitted  with  a 
suitable  indicator  to  take  the  place  of  the  indicator  now  afforded 
by  the  relation  of  the  horizontal  portion  of  the  traction  rods  to  the 
handles. 


988  OBSTETRICAL  OPERATIONS 

The  Action  of  the  Forceps. — The  forceps  can  be  used  for  several 
distinct  purposes.  It  can  be  used  as  a  tractor,  rotator,  compressor, 
or  dilator.  Its  chief  and  most  important  use  is  as  a  simple  tractor, 
that  is,  as  a  means  of  applying  the  necessary  traction  to  the 
head  to  draw  it  downwards  through  the  pelvis.  Occasion- 
ally, it  is  permissible  to  use  it  as  a  rotator,  with  the  object  of 
bringing  about  the  necessary  internal  rotation  of  the  head.  This 
use  is  seldom  required  save  in  cases  of  occipito-posterior  position 
of  the  head,  as  we  shall  subsequently  see.  The  use  of  the  forceps 
as  a  compressor,  i.e.,  as  a  means  of  lessening  certain  diameters, 
is  not  one  to  be  recommended.  The  forceps  most  usually  lies  in 
relation  to  a  transverse  or  oblique  diameter  of  the  pelvis,  and 
it  is  but  rarely  that  these  diameters  offer  an  obstruction  to  the 
passage  of  the  head,  unless  there  is  at  the  same  time  a  greater 
degree  of  obstruction  in  the  antero-posterior  diameters,  in  which 
case  the  compression  of  the  diameters  of  the  head  which  lie  in 
the  transverse  or  oblique  diameters  of  the  pelvis  is  of  little 
advantage.  Further,  if  the  foetus  is  alive,  compression  is  danger- 
ous, while  if  the  foetus  is  dead  and  compression  of  the  head  is 
necessary  in  order  that  it  may  be  delivered,  there  are  other  and 
better  methods  of  effecting  delivery.  The  use  of  the  forceps  as 
a  dilator  of  the  uterine  orifice  is  also  inadvisable.  If  possible, 
the  forceps  should  never  be  applied  unless  the  uterine  orifice  is 
sufficiently  dilated  to  allow  the  passage  of  the  head,  and,  in  the 
rare  cases  in  which  it  is  necessary  to  do  so,  preliminary  dilatation 
should  be  effected  or  the  cervix  incised. 

Indications. — The  indications  for  the  use  of  the  forceps  can  be 
divided  into  two  groups : — Indications  on  behalf  of  the  child  ; 
and,  indications  on  behalf  of  the  mother. 

In  the  first  group  are  the  following  indications : — 

(i)  A  foetal  heart-rate  rising  progressively  above  160  in  the 
interval  between  the  pains,  or  falling  below  120. 

(2)  Tumultuous  movements  on  the  part  of  the  foetus. 

(3)  The  coming  away  of  meconium,  unmixed  with  liquor 

amnii,  in  a  head  presentation. 

(4)  Prolapse  of  the  cord. 

In  the  second  group  are  the  following  indications : — ■ 

(1)  Accidental  haemorrhage  and  placenta  praevia. 

(2)  Threatened  rupture  of  the  uterus. 

(3)  Unduly   prolonged   second    stage,    as   shown    by   the 

exhausted  condition  of  the  patient. 

(4)  Convulsions. 

(5)  Cardiac,    pulmonary,    renal,    or   other   form    of  grave 

organic  disease. 

(6)  Haematoma  of  the  vulva. 

The  foregoing  indications  must  not  all  be  regarded  as  equally 
absolute.  Provided  the  conditions  necessary  for  the  safe  applica- 
tion of  the  forceps  are  fulfilled,  they  are  all  absolute,  because 
under  these  circumstances  the  forceps  furnishes  the  best  means 


INDICATIONS  FOR  THE   USE  OF  THE  FORCEPS  989 

of  delivering  the  fcetus  with  a  minimum  of  risk  to  it  and  to  the 
mother.  If,  however,  these  conditions  are  not  fulfilled,  then  it 
is  necessary  to  decide  whether  the  danger  incurred  by  waiting  is 
so  great  as  to  necessitate  the  immediate  delivery  of  the  fcetus, 
and,  if  it  is  so  great,  whether  the  forceps  offers  the  best  means  of 
effecting  delivery  under  the  circumstances. 

For  the  safe  and  easy  application  of  the  forceps,  the  following 
conditions  must  be  fulfilled  : — 

(1)  The  uterine  orifice  must  be  sufficiently  dilated  to  allow  the 
passage  of  the  fetus.  If  it  is  not  so  dilated  we  are  using  the 
forceps  not  alone  as  a  tractor,  but  as  a  dilator,  and,  as  we  have 
said,  it  is  preferable  to  first  effect  dilatation  of  the  cervix,  and 
then  to  apply  the  forceps,  rather  than  to  drag  the  fcetal  head 
through  an  imperfectly  dilated  orifice  and  to  run  the  risk  of 
causing  deep  lacerations  of  the  cervix.  If,  as  sometimes  happens, 
the  forceps  must  be  applied  through  an  imperfectly  dilated  orifice, 
traction  must  be  made  with  extreme  slowness  and  gentleness,  in 
order  to  avoid  laceration. 

(2)  The  foetus  must  present  by  the  vertex,  or  posterior 
fontanelle,  or,  if  the  face  presents,  the  chin  must  have  rotated 
forwards.  In  other  presentations  of  the  head,  it  is  doubtful 
whether  the  forceps  offers  a  better  prospect  of  effecting  delivery 
than  do  the  unaided  uterine  contractions,  and  probably  it  is  only 
when  the  latter  are  feeble  that  the  forceps  will  prove  of  service. 

(3)  The  greatest  diameter  of  the  head  must  have  entered  the 
pelvic  brim.  Even  in  a  normal  pelvis  and  with  an  axis-traction 
forceps,  there  is  always  a  difficulty  in  pulling  a  head  which  is  free 
above  the  brim  into  and  through  the  latter.  It  must  be  remem- 
bered that  an  axis-traction  forceps  only  enables  one  to  pull  in  the 
direction  of  the  axis  of  the  upper  half  of  the  blades  of  the  forceps. 
If  this  portion  of  the  blades  lies  in  the  axis  of  the  pelvic  inlet, 
then  our  traction  will  correspond  with  that  axis,  but  if  the  blades 
do  not  so  lie,  then  our  traction  will  not  be  made  in  the  axis  of  the 
inlet.  If  the  head  is  fixed  in  the  brim,  the  pelvic  curve  of  the 
forceps,  and  the  manner  in  which  the  latter  adapts  itself  to  the 
head,  ensure  that,  for  all  practical  purposes,  the  axis  of  the  blades 
lies  in  the  required  position,  but  when  the  head  is  free  to  move 
about  above  the  brim  there  is  no  certainty  that  it  will  so  lie. 
Rather,  there  is  the  extreme  probability  that  we  are  wasting  a 
certain  amount  of  energy  in  pulling  the  head  against  the 
symphysis.  Further,  if  the  head  is  lying  at  the  brim  in  an 
asynclitic  position,  the  forceps  tends  to  drag  it  downwards  in  this 
position,  and  prevents  it  from  gradually  correcting  itself,  as  it 
would  do  if  acted  on  by  the  uterine  contractions  alone.  Lastly, 
if  the  head  is  free  above  the  brim  at  a  time  when  there  is  an 
indication  for  immediate  delivery,  it  is  probable  that  there  is  a 
disproportion  between  the  head  and  the  brim  ;  and  this  dispropor- 
tion is  bound  to  be  increased  by  the  lateral  expansion  of  the 
head  that  results  when  the  blades  of  the  forceps  drag  the  base 


99Q  OBSTETRICAL  OPERATIONS 

of  the  skull  downwards,  and  the  rigid  pelvic  ring  presses  the 
calvarium  upwards. 

Several  writers  are  opposed  to  the  belief  that  compression  of 
the  head  by  the  forceps  in  one  horizontal  diameter  causes  a  corre- 
sponding increase  in  the  length  of  the  other  horizontal  diameters. 
Milne  Murray,  in  particular,  made  a  series  of  interesting  experi- 
ments on  dead  infants,  which  went  to  show  that  compression 
of  the  head  with  a  cephalotribe  in  one  horizontal  diameter  did 
not  cause  a  compensatory  increase  in  the  length  of  the  other 
horizontal  diameters  of  the  head,  but  only  caused  an  increase  in 
the  vertical  diameters.     We  confess  we  find  some  difficulty  in 
accepting,  this  as  correct,  but,  assuming  it  to  be  so  in  the  case  of 
horizontal   compression,  it  does  not  disprove  the  occurrence  of 
compensatory  lateral   increase   in   the   case  with  which  we   are 
now  concerned.     When  the  head  is  dragged  downwards  on  to  a 
narrow  pelvic  brim,  it  is  compressed,  not  so  much  laterally,  as 
vertically,   the  base  being  dragged  downwards  by  the  forceps, 
the  calvarium   being  pressed  upwards  by  the  pelvis.      Such  a 
compression  is  bound  to  cause  lateral  expansion  of  the   head, 
as   the   lateral   diameters  are  the   only  ones  which  are  free  to 
expand.     A  similar  compression  also  occurs  when  the  head  is 
acted   upon    by   the   uterine    contractions   alone,  but    here    the 
natural  mechanism  which  the  head  follows  minimises  the  effect 
of  this  compression,  and  sufficient  time  is  afforded  for  the  head 
to   alter  its  shape   to    suit  the   conditions    present.      For  these 
reasons,  we  consider  that,  instead  of  contracted  pelvis  being  an 
indication  for  the  application  of  the  forceps,  it  is  a  contra-indica- 
tion,  and  that  the  use  of  the  forceps  is  only  permissible  as  a  last 
resource,  which  failing  us,  we  are  prepared  to  perform  perforation. 
(4)    Uterine   contractions    must   be   occurring   with    sufficient 
regularity  and  force  to  ensure  the  subsequent  detachment  and 
expulsion  of  the  placenta,  and  the  closure  of  the  uterine  sinuses. 
The  danger  of  the  occurrence  of  post-partum  haemorrhage  in  the 
presence  of  uterine  inertia  is  considerable,  although  in  some  cases 
delivery  by  the  forceps  appears  to  act  beneficially  on  the  con- 
tractions and   to  serve   to    stimulate  them.      Uterine  inertia  is 
frequently   given    as   an    indication   for   the   application   of    the 
forceps,  but  we  consider  it  more  correct  to  regard  it  as  a  contra- 
indication to  their  use.      The  presence  of  uterine  inertia  may 
necessitate  the  use  of  the  forceps,  it  never  indicates  its  use. 

The  Application  of  the  Forceps  in  Vertex 
Presentation. 

During  the  application  of  the  forceps,  the  patient  may  be  placed 
in  the  left  lateral  position  or  on  the  back.  In  this  country, 
it  is  usual  to  adopt  the  former  position.  It  requires  less  assist- 
ance, as  a  single  nurse  can  easily  manage  the  patient  when  on 
the  side,  while,  if  she  is  placed  in  the  dorsal  cross-bed  position, 


THE  FORCEPS  IN   VERTEX  PRESENTATION 


991 


two  assistants  are  usually  required — one  to  hold  each  leg.  It 
offers  the  further  advantage  that  it  is  more  easy  to  follow  the 
advance  of  the  head  and  to  take  effective  measures  for  the  pro- 
tection of  the  perinaeum.  On  the  other  hand,  if  the  case  requires 
the  exertion  of  a  considerable  amount  of  traction  force,  it  is  easier 
to  apply  the  latter  with  the  patient  on  the  back.  If  the  side 
position  is  chosen,  the  patient  is  placed  as  shown  in  Fig.  412, 


Fig,  412  — The  Introduction  of  the  Lower  Blade  of  the  Forceps. 


the  buttocks  projecting  slightly  beyond  the  side  of  the  bed,  and 
the  thighs  and  legs  flexed.  During  the  introduction  of  the  blades, 
the  nurse  holds  the  right  leg  as  shown,  but,  as  soon  as  traction 
is  commenced,  she  should  sit  on  the  bed  behind  the  patient's 
back,  and,  bringing  the  left  hand  round  the  thigh  from  inside 
and  the  right  hand  round  from  outside,  clasp  them  firmly  so 
as  to   encircle  the  thigh   just  above  the  fold  of  the  nates.     In 


992 


OBSTETRICAL  OPERATIONS 


this  position,  she  can  provide  the  necessary  counterstrain  to  the 
traction  force  exerted  by  the  operator,  and  so  prevent  the  patient 
from  slipping  too  far  off  the  bed. 

As  soon  as  the  patient  has  been  thoroughly  washed,  disinfected, 
and  anaesthetised,  the  bladder  is  emptied  with  a  catheter,  and  the 
membranes  ruptured.  A  careful  vaginal  examination  is  then  made 
to  determine  the  exact  presentation  and  position  of  the  head  and 


Fig.  413. — Rotation  of   the   Handle    of   the   Lower   Blade   of   the 
Forceps  to  bring  the  Blade  to  the  Left  Side  of  the  Pelvis. 


its  relation  to  the  pelvis,  the  condition   of  the  cervix,  and   the 
presence  of  any  abnormality  of  the  pelvic  walls  or  the  soft  parts. 

There  are  two  methods  of  applying  the  forceps,  both  of  which 
have  their  advocates.  The  first  consists  in  applying  it  in  relation 
to  the  pelvis,  so  that  one  blade  lies  at  one  side  of  the  pelvis, 
the  other  blade  at  the  opposite  side,  without  taking  into  con- 
sideration the  position  of  the  head.  The  other,  the  cephalic 
method,  in  which  the  forceps  is  applied  in  a  fixed-^r elation  to  the 


THE  FORCEPS  IN   VERTEX  PRESENTATION 


993 


head  whatever  may  be  the  position  of  the  latter,  is  undoubtedly 
the  more  correct,  and  is  the  method  which  will  allow  the  head  to 
be  extracted  with  the  least  force. 

The  pelvic  method  of  applying  the  forceps  is  the  easier,  and  is 
probably  the  one  almost  universally  adopted  in  these  countries. 
It  means  that  the  forceps  always  lies  in  relation  to  either  the 
transverse  or  the  oblique  diameter  of  the  pelvis,  and  that  con- 
sequently the   pelvic  curve  of  the   forceps  always  corresponds 


Fig.  414. — The  Lower  Blade  of  the  Forceps  in  situ. 


more  or  less  exactly  with  the  curve  of  the  pelvis.  On  the  other 
hand,  owing  to  the  irregular  manner  in  which  the  head  is  seized, 
difficulty  may  be  experienced  in  locking  the  forceps,  and  the 
head  may  be  injured  by  compression. 

In  the  cephalic  method,  the  forceps  is  applied  in  a  vertex 
presentation  so  that  the  blades  lie  along  each  side  of  the  head, 
the  long  axis  of  the  fenestrae  corresponding  as  exactly  as  possible 
with  the  supra-occipito-mental  or  the  occipito-mental  diameter  of 
the  head  (v.  Fig.  420).    This  method  was  recommended  by  Smellie 

63 


994 


OBSTETRICAL  OPERATIONS 


and  Baudelocque,  and  though  for  a  time  given  up,  was  re-introduced 
by  the  modern  French  obstetricians.  At  the  present  time,  it  is 
strongly  advocated  by  Pinard,  Ribemont-Dessaignes,  and  Whit- 
ridge  Williams.  The  first-named  stated  that  whatever  was  the 
height  or  position  of  the  head,  it  should  be  gripped  in  a  regular 
manner,  as  we  have  just  described.  Williams  and  Farabceuf,  how- 
ever, rightly  point  out  that  when  the  head  is  free  above  the  brim  it 
is  not  possible  to  grip  it  transversely,  since  the  head  when  in  this 
position  usually  lies  with  its  antero-posterior  diameters  correspond- 
ing to  the  transverse  diameters  of  the  pelvis,  and,  consequently, 


Fig.  415. — The  Introduction  of  the  Upper  Blade  of  the  Forceps. 


the  forceps,  if  applied  to  the  sides  of  the  head,  will  also  lie  in  the 
conjugate  diameter  of  the  pelvis.  Such  a  position  is  objection- 
able for  several  reasons.  In  the  first  place,  the  blades  take  up 
a  certain  amount  of  room,  and  so  make  still  more  narrow  the 
presumably  already  narrowed  conjugate.  Then,  the  pelvic  curve 
of  the  forceps  no  longer  corresponds  with  the  curve  of  the  pelvis, 
and,  consequently,  it  is  impossible  to  exert  traction  with  them 
in  the  required  direction,  and,  even  if  the  head  is  brought  down 
into  the  brim,  the  posterior  blade  bridges  across  the  sacral  con- 
cavity and  prevents  the  head  from  descending.  In  all  cases,  how- 
ever, in  which  the  head  is  in  the  pelvic  cavity  or  at  the  outlet, 


THE  FORCEPS  IN   VERTEX  PRESENTATION 


995 


Williams  and  Faraboeuf  agree  that  the  cephalic  application  of 
the  forceps  is  the  proper  one,  and  that,  even  if  the  head  lies 
with  its  antero-posterior  diameters  in  relation  to  the  transverse 
diameters  of  the  pelvis  and  the  forceps  has  to  be  applied  in  the 
conjugate,  cephalic  application  is  still  the  better  method.  The 
advantages  of  this  method  of  application  are  three : — First,  that 
a  firm  grip  of  the  child's  head  is  obtained  ;  secondly,  that  the 
head  is  seized  in  the  least  injurious  manner ;  and,  thirdly,  that 


Fig.  416.— Rotation  of  the  Handle  of  the  Upper  Blade  to  bring 
the  Blade  to  the  Right  Side  of  the  Pelvis. 


the  head  is  pulled  down  in  the  natural  position  of  flexion,  and 
that  a  minimum  amount  of  force  is  required. 

With  regard  to  a  choice  between  the  two  methods  of  apply- 
ing the  forceps,  we  are  not  going  to  say  much.  Every  obstet- 
rician has  been  brought  up  to  practise  one  or  the  other,  and  he 
will  probably  adhere  to  that  with  which  he  is  most  familiar.  It  is 
important  to  remember  that  in  the  majority  of  cases  there  is  no 

63—2 


996  OBSTETRICAL  OPERATIONS 

essential  difference  between  the  two  methods,  inasmuch  as  the 
head  most  frequently  lies  with  the  occiput  to  the  left  and  in  front, 
and  in  such  cases,  whether  the  mode  of  application  chosen  is  the 
pelvic  or  the  cephalic,  the  forceps  will  grip  the  head  transversely, 
and  in  relation  to  the  mento-occipital  diameter.  Consequently, 
it  is  only  in  atypical  positions  of  the  head  that  the  one  method 
differs  from  the  other.  These  are,  however,  just  the  cases  in 
which  difficulties  often  arise  and  in  which  every  manoeuvre  that 
facilitates  delivery  is  of  assistance.     For  this  reason,  we  advise 


Fig.  417.  —The  Blades  Locked,  and  the  Axis-traction  Apparatus 

applied. 

The  head  is  engaged  in  the  brim  ;  note  the  direction  in  which 
traction  is  made. 

the  student  to  learn  both  methods,  and,  in  all  cases,  so  far  as 
possible,  to  endeavour  to  apply  the  forceps  in  whatever  manner 
enables  the  head  to  be  delivered  with  the  least  amount  of  force. 

We  must  now  describe  in  detail  the  steps  in  the  application 
of  the  forceps  in  each  method,  and  will  commence  with  the 
pelvic  method,  as  it  is  the  more  common. 

The  Pelvic  Method. — When  the  patient  lies  in  the  left  lateral 
position,  the  left  or  lower  blade  of  the  forceps  is  taken  in  the 


THE  FORCEPS  IN   VERTEX  PRESENTATION 


997 


right  hand  as  is  shown  in  Fig.  412,  and  the  left  hand  is  passed 
into  the  vagina  and  upwards  into  the  hollow  of  the  sacrum 
behind  the  head,  and  the  fingers  are  slipped  inside  the  lips  of  the 
cervix,  if  any  portion  of  the  latter  can  be  felt.  It  is  essential 
to  introduce  the  hand  so  far  as  is  necessary  to  make  certain  that 
no  portion  of  cervix  remains,  as  otherwise  the  blade  may  be 
passed  outside  the  cervix,  and  so  include  the  latter  between  it 
and  the  foetal  head.     If  this  happened,  as  soon  as  traction  was 


Fig.  418, 


-The  Direction  in  which  Traction  is  made  as  the  Head 
comes  on  to  the  perineum. 


made  we  should  be  dragging  down  not  only  the  head,  but  also 
the  uterus,  and  most  serious,  if  not  fatal,  consequences  might 
result.  The  blade  is  then  entered  as  is  shown  (v.  Fig.  412), 
and  the  point  is  slipped  upwards  along  the  palm  of  the  hand 
until  it  has  passed  above  the  greatest  convexity  of  the  head.  The 
handle  is  then  gently  rotated  in  the  direction  shown  by  the  arrow 
until  it  comes  to  occupy  the  position  shown  in  Fig.  413.  If  we 
consider  the  effect  which  this  movement  of  the  handle  has  upon 
the  blade,  we  shall  see  that  it  makes  the  blade  move  in  an  opposite 


99S  OBSTETRICAL  OPERATIONS 

direction,  so  as  to  travel  round  the  head  and  come  to  lie  in 
approximate  relation  to  the  left  end  of  the  transverse  diameter. 
The  handle  is  then  carried  further  backwards  into  the  middle  line 
until  it  comes  to  lie  in  the  position  shown  in  Fig.  414,  a  move- 
ment which  has  the  effect  of  carrying  the  blade  higher  into  the 
pelvis  and  more  fully  round  the  greatest  convexity  of  the  head. 
This  blade  is  now  in  position  and  is  maintained  there  either  by 
an  assistant  or  by  slight  pressure  with  the  palm  of  the  vaginal 
hand.  The  right  blade  is  next  taken,  and  is  introduced  in  a 
similar  manner  save  that  the  rotation  of  the  handle  is  made  in 


Fig.  419. — The  Direction  in  which  Traction  is  made  as  the  Head 
is  passing  through  the  Vulva. 

the  opposite  direction,  so  as  to  bring  the  blade  to  lie  in  relation  to 
the  right  end  of  the  transverse  diameter  of  the  pelvis  (v.  Figs.  415, 
416).     The  handles  are  then  crossed  and  interlocked. 

We  have  said  in  our  description  that  the  blades  are  brought  to 
lie  at  the  opposite  ends  of  the  transverse  diameter  of  the  pelvis, 
but,  as  a  matter  of  fact,  it  is  but  rarely  they  remain  in  this 
position.  If  the  head  lies  with  its  antero-posterior  diameters 
corresponding  to  one  oblique  diameter,  the  forceps  tends  to  slip 
round  until  it  lies  in  the  opposite  oblique  diameter. 

If  the  forceps  is  applied  with  the  patient  in  the  dorsal  cross- 
bed  position,  the  manner  of  introducing  the  blades  differs  slightly. 


THE  FORCEPS  IN   VERTEX  PRESENTATION  999 

The  left  lower  blade  is  still  introduced  first,  but  it  is  held  in  the 
left  hand,  while  the  right  hand  serves  as  the  vaginal  guide.  The 
right  blade,  on  the  other  hand,  is  held  in  the  right  hand,  while 
the  left  hand  serves  as  the  vaginal  guide.  If  the  head  is  high  in 
the  pelvis,  the  operator  must  sit  upon  a  low  seat,  as  otherwise 
he  will  not  be  able  to  get  his  hands  sufficiently  low  to  pull  in  the 
correct  direction. 

The  Cephalic  Method.  —  The  principal  points  of  difference 
between  the  cephalic  and  the  pelvic  methods  of  applying  the 
forceps  are  as  follows: — As  soon  as  the  patient  has  been  thoroughly 
washed  and  disinfected,  introduce  as  much  of  the  hand  as  is 
necessary  and  determine  the  position  of  the  posterior  ear.     Then, 


Fig.  4-20. — The  Relation  of  the  Forceps  :to  the  Head  in  a  First 
Vertex  Presentation  with  the  Back  in  Front. 

apply  over  that  ear  the  corresponding  blade  of  the  forceps.  If 
the  ear  is  directed  to  the  left  side  of  the  pelvis,  apply  the  left 
blade ;  if  to  the  right  side,  apply  the  right  blade.  If  the  head  lies 
transversely,  apply  the  left  blade  if  the  occiput  points  to  the  left, 
and  the  right  blade  if  the  occiput  points  to  the  right.  If  the  head 
lies  antero-posteriorly,  and,  consequently,  neither  ear  is  posterior 
to  its  fellow,  apply  the  left  blade  first  over  the  ear  which  is 
directed  towards  the  left  side.  As  soon  as  the  first  blade  is  in 
position,  apply  the  second  blade  over  the  opposite  ear.  The 
blades  are  guided  into  position  by  means  of  a  hand  in  the 
vagina  passed  upwards  beside  the  head,  as  has  been  described. 
If  the  patient  is  lying  on  the  left  side,  the  left  hand  is  introduced 
in  all  cases  into  the  vagina.     If  the  patient  is  lying  on  the  back, 


iooo  OBSTETRICAL  OPERATIONS 

the  right  hand  is  introduced  when  the  left  blade  is  being  applied, 
the  left  hand  when  the  right  blade  is  being  applied.  In  all  cases, 
we  endeavour  to  make  the  forceps  lie  with  the  blades  over  the 
ears,  and  with  its  long  axis  corresponding  to  the  occipito-mental 
or  sub-occipito-bregmatic  diameter  of  the  head  (v.  Figs.  420, 
421).  In  cases  in  which  the  right  blade  is  applied  first,  a  slight 
difficulty  will  arise  in  that,  when  the  left  blade  is  introduced,  it 
will  lie  above  the  right,  and  the  locks  will  not  fall  together..  This 
difficulty  can  be  overcome  by  rotating  the  left  handle  round  the 
right  handle,  and  so  bringing  them  into  their  correct  relation. 

It  will   be  noticed  that,  if  the  instructions  given  above  are 
followed,  when  the  head  lies  with  its  antero-posterior  diameters 


Fig.  421. — The  Relation  of  the  Forceps  to  the  Head  in  a  Second 
Vertex  Presentation  with  the  Back  in  Front. 

corresponding  to  the  transverse  diameter  of  the  pelvis,  the 
forceps  will  lie  in  the  antero-posterior  diameter  of  the  pelvis. 
This  position,  although  it  discounts  the  existence  of  the  pelvic 
curve  of  the  forceps,  is,  as  we  have  already  said,  sanctioned  by 
French  writers  in  all  cases  in  which  the  head  lies  in  the  pelvic 
cavity  or  near  the  outlet.  Pinard  advises  its  use  in  cases  in  which 
the  head  is  above  the  brim,  but  he  appears  to  be  the  only  writer 
to  do  so,  and,  indeed,  the  practice  appears  open  to  too  many 
objections  to  need  consideration. 

The  forceps  having  been  applied  by  whichever  method  is 
thought  best,  the  next  point  is  to  extract  the  foetus.  As  soon  as 
the  blades  have  been  locked,  the  axis-traction  apparatus  is  applied, 
the   butterfly-nut  that  holds  the  blades  together  is  screwed  up 


THE  FORCEPS  IN  OCCIPITO-POSTERIOR  POSITIONS         iooi 

just  sufficiently  tightly  to  prevent  the  blades  from  falling  apart, 
and  traction  is  made  as  shown  in  Fig.  417.  At  first,  traction 
should  be  made  with  one  hand,  and  it  is  only  in  the  event  of 
this  proving  insufficient  that  both  hands  are  used.  Traction  is 
made  intermittently,  and,  if  uterine  contractions  are  occurring, 
should  be  made  concurrently  with  them.  The  direction  in  which 
to  pull  is  shown  by  the  indicator  on  the  axis-traction  apparatus. 
If  the  head  is  entering  the  brim,  we  first  pull  downwards  and 
backwards  in  the  axis  of  the  inlet  (v.  Figs.  417-419).  Then, 
as  the  head  passes  into  the  pelvic  cavity,  we  pull  almost  directly 
downwards,  then  directly  downwards,  then,  as  the  head  approaches 
the  outlet,  downwards  and  forwards,  and,  lastly,  as  the  head 
emerges,  almost  directly  forwards.  As  the  head  is  passing  over 
the  perinaeum,  the  forceps  may  be  removed,  or  be  allowed  to 
remain.  Many  writers  recommend  its  removal,  but  Milne  Murray 
considered  that  a  great  part  of  the  value  of  axis-traction  was 
lost  by  doing  so.  Personally,  we  do  not  consider  that  it  is  a 
matter  of  much  importance  which  course  is  adopted.  The 
advantage  of  removing  the  forceps  is  that  the  head,  when  born, 
is  free,  and  the  forceps  is  out  of  the  way. 

The  Application  of  the   Forceps   in   Presentations  other 
than  the  vertex. 

So  far,  our  remarks  have  been  intended  to  apply  to  the  use  of 
the  forceps  in  vertex  presentation  only,  but  there  are  also  other 
presentations  in  which  the  forceps  may  have  to  be  used,  and  with 
these  we  must  now  deal.  We  may  preface  what  we  have  to 
say  by  repeating  that,  for  the  safe  and  easy  application  of  the 
forceps,  the  vertex  must  present.  In  all  other  presentations  the 
application  of  the  forceps  is  difficult,  and  attended  with  risk  ; 
consequently,  it  is  only  in  the  presence  of  an  urgent  indication  for 
delivery  that  the  forceps  ought  to  be  applied  in  such  cases. 

In  Occipito-posterior  Position  of  the  Head. — It  not  infrequently 
happens  that,  in  consequence  of  delay  during  the  second  stage  of 
'labour  due  to  failure  of  an  occipito-posterior  position  of  the  head 
to  rotate,  the  forceps  has  to  be  applied.  In  such  cases,  during 
extraction  of  the  head,  internal  rotation  may  so  occur  as  to  bring 
the  occiput  either  directly  posterior  or  forwards  beneath  the  arch 
of  the  pubes.  In  the  former  case,  delivery  is  more  difficult,  and 
deep  lacerations  of  the  perinaeum  and  vagina  may  occur.  In  the 
latter  case,  the  forceps  will  rotate  with  the  head,  and  turn  so 
that  its  pelvic  curve  is  looking  backwards  instead  of  forwards, 
thus  necessitating  its  removal  and  re-application.  This,  however, 
is  easy  to  do,  and,  accordingly,  if  possible,  the  head  must  be 
made  to  rotate  in  such  a  direction  as  to  bring  the  occiput 
anteriorly.  In  all  cases,  the  forceps  is  applied  so  far  as  possible 
to  the  sides  of  the  head,  the  pelvic  curve  directed  towards  the 
face,  i.e.,  anteriorly.     If   the  head  is  not  already  on   the  pelvic 


1002  OBSTETRICAL  OPERATIONS 

floor,  traction  is  made,  and  it  is  pulled  down  on  to  the  latter. 
Then,  if  traction  is  continued,  the  head  will  in  some  cases  rotate 
of  itself  under  the  influence  of  the  pelvic  floor,  and  bring  the 
occiput  anteriorly.  If  it  does  not  do  so,  Whitridge  Williams 
recommends*  gentle  rotation  of  the  forceps  during  traction  in 
such  a  manner  as  to  bring  the  occiput  forwards.  If  such  a 
rotation  occurs,  the  forceps  must  be  removed  and  re-introduced 
in  a  proper  position,  as  has  been  already  described.  If  the  head 
cannot  be  made  to  rotate  forwards,  the  exertion  of  a  considerable 
amount  of  force  will  probably  be  required  in  order  to  effect 
delivery.     As  the  occiput  is  emerging,  the  handles  of  the  forceps 


Fig.  422. — The   Relation    of    the    Forceps   to   the    Head    in    an 
Uncorrected  Occipito-posterior  Position  of  the  Vertex. 


must  be  carried  well  forward  towards  the  abdomen  of  the  mother, 
and  then,  as  soon  as  the  occiput  is  born,  carried  backwards  in 
order  to  bring  the  face  from  behind  the  symphysis. 

In  Face  Presentation.  —  The  forceps  may  be  occasionally 
required  in  face  presentation,  but  as  a  rule  it  is  better  if 
possible  to  avoid  its  use.  If  it  is  used,  it  is  essential  in  the 
interests  of  the  foetus  that  the  cephalic  method  of  application  is 
adopted,  as  the  forceps,  irregularly  applied  to  the  head  in  a  face 
presentation,  may  directly  bring  about  the  death  of  the  foetus  by 
causing  pressure  on  the  vessels  and  nerves  of  the  neck.  The 
forceps  can  be  applied  provided  the  face  lies  either  transversely 

*  Op.  cit.,  p.  372. 


THE  FORCEPS  IN  BROW  AND  PELVIC  PRESENTATIONS     1003 

in  the  pelvis  or  antero-posteriorly  with  the  chin  in  front.  When 
the  chin  has  rotated  backwards,  its  use  is  not  alone  contra- 
indicated  but  absolutely  forbidden.  Once  the  chin  has  rotated  in 
front,  the  extraction  of  the  child  is  comparatively  easy,  but  the 
forceps  is  rarely  required  in  such  cases,  as  spontaneous  expulsion 
usually  quickly  follows.  Extraction  in  cases  in  which  the  face  lies 
transversely  is  more  difficult,  as  rotation  in  the  proper  direction 
must  precede  delivery.  In  both  cases,  the  forceps  is  so  applied  that 
the  blades  grasp  the  sides  of  the  head,  and  the  axis  of  the  fenestra 
corresponds  approximately  to  a  diameter  between  the  occipito- 
frontal and  the  supra-occipito-mental  diameters.  If  the  head  lies 
transversely  in  the  pelvis,  the  blades  will  lie  antero-posteriorly. 
Traction  is  first  made  downwards  until  rotation  occurs,  and,  as 
the  face  appears,  the  handles  are  carried  gradually  forwards  over 
the  mother's  abdomen  in  such  a  manner  as  to  make  the  occiput 
roll  out  from  above  the  perinaeum. 


Fig.  423. — The  Relation  of  the  Forceps  to  the  Head  in  a  Face 
Presentation  after  Forward  Rotation  of  the  Chin. 

In  Brow  Presentation. — The  use  of  the  forceps  in  brow  presenta- 
tion is  only  indicated,  in  cases  in  which  the  foetus  is  still  alive, 
as  a  last  resource  prior  to  the  performance  of  perforation.  In 
such  cases,  it  is  applied  to  the  sides  of  the  head  with  the  long 
axis  of  the  upper  part  of  the  blades  corresponding  approximately 
to  the  sub-occipito-frontal  diameter  of  the  head.  Traction  is  first 
made  in  such  a  direction  as  to  bring  the  head  on  to  the  pelvic 
floor,  if  it  has  not  already  reached  it.  Then,  if  the  face  rotates 
in  front,  delivery  may  possibly  be  effected  by  carrying  the  handles 
forward  so  as  to  bring  the  vertex  and  occiput  from  above  the 
perinaeum.  If  the  face  rotates  posteriorly,  delivery  with  the 
forceps  is  practically  impossible. 

In  Pelvic  Presentation. — In  pelvic  presentations,  the  forceps  can 
be  used  to  extract  either  the  breech  or  the  after-coming  head. 
Their  extraction  can,  however,  be  better  effected  by  other  means, 
and  consequently  we  do  not  propose  to  discuss  the  use  of  the 
forceps  in  this  presentation. 


1004 


OBSTETRICAL  OPERATIONS 


Prognosis. — The  prognosis  for  both  mother  and  child  in  forceps 
cases  depends  on  whether  the  latter  is  applied  properly  in 
suitable  cases,  or  whether  it  is  used  in  a  haphazard  manner 
in  every  case  that  requires  delivery.  Used  correctly,  the 
forceps  per  se  has  no  associated  mortality  rate ;  used  improperly, 
it  has  been  described  by  Leopold  as  the  most  bloody  of  all 
obstetrical  operations.  The  dangers  attached  to  its  use  in  the 
case  of  the  mother  are  the  introduction  of  sepsis  and  the  occur- 
rence of  lacerations.  If  aseptic  midwifery  is  habitually  practised 
there  is  no  more  reason  that  the  patient  should  be  infected  during 
the  application  of  the  forceps  than  during  an  ordinary  labour.  If 
asepsis  is  neglected,  naturally  the  increased  intra  vaginal  manipula- 
tions necessitate  an  increased  risk  of  infection.  Lacerations  of  a 
serious  type  are  specially  prone  to  occur  if  the  forceps  is  im- 
properly aptplied  or  applied  in  unsuitable  cases,  and  may  involve 
the  vaginal  vault,  the  cervix,  and  the  lower  uterine  segment, 
causing  serious  after-consequences  and  even  the  immediate  death 
of  the  patient.  Even  in  skilled  hands  and  in  suitable  cases, 
laceration  of  the  vagina  and  perinaeum  may  occur,  but  such 
lacerations,  if  properly  treated,  rarely  cause  any  after-trouble. 

The  principal  dangers  attached  to  the  use  of  the  forceps  in  the 
case  of  the  foetus  are,  first,  death  from  too  long  continued  or  too 
great  compression  of  the  head,  or  from  the  force  with  which  the 
latter  is  dragged  against  a  narrow  pelvic  brim,  and,  secondly, 
temporary  injuries  due  either  to  the  pressure  of  the  blade  of  the 
forceps  or  to  compression  by  some  bony  prominence.  The  pres- 
sure of  the  forceps'  blade  not  uncommonly  gives  rise  to  a  slight 
degree  of  facial  paralysis,  due  to  pressure  on  the  facial  nerve. 
The  condition,  however,  passes  off  in  a  few  days.  Pressure  of 
the  forceps'  blade  on  the  neck  may  give  rise  to  serious  conse- 
quences and  must  be  strictly  avoided. 

Perhaps  a  fairly  correct  idea  of  the  risks  of  forceps'  application, 
when  properly  performed  in  hospital  practice,  may  be  afforded  by 
the  following  table  based  on  the  statistics  of  the  Rotunda  Hospital 
during  the  Mastership  of  Purefoy— i.e.,  from  1896-1903  : — 


No.  of 
Deliveries. 

No.  of 
Forceps 
Cases. 

Deaths. 

Percentage 

of  Forceps 

Cases 

per  100 

Labours. 

Percentage 
of  Maternal 

Deaths  per 

100  Forceps 

Cases. 

Percentage 

of  Foetal 

Deaths  per 

100  Forceps 

Cases. 

Maternal. 

Fcetal. 

11,098 

431 

0                 60 

3-8                    0 

13  Q2 

CHAPTER  III 
VERSION,  AND  EXTRACTION  IN  PELVIC  PRESENTATION 

Version — Varieties — Indications — Contra-indications — Methods  of  Perform- 
ing Version — External  Version — Combined  or  Bi-polar  Version — Internal 
Version — The  Extraction  of  the  Foetus  in  Pelvic  Presentation — The 
Extraction  of  the  Pelvic  Pole — The  Liberation  and  Delivery  of  the 
Arms — The  Delivery  of  the  After-coming  Head  ;  The  Prague  Method, 
Martin's  Method,  Smellie's  Method,  The  Application  of  the  Forceps. 

VERSION 

Version  or  turning  is  the  term  applied  to  the  operation  by  which 
one  polar  presentation  is  substituted  for  another,  or  a  longitudinal 
lie  is  substituted  for  a  transverse  lie.  Thus,  a  shoulder  presenta- 
tion or  a  pelvic  presentation  may  be  changed  by  version  into  a 
cephalic  presentation,  or  a  shoulder  presentation  or  a  cephalic 
presentation  into  a  podalic  presentation. 

There  are  two  varieties  of  version,  each  named  after  the  resultant 
presentation.     These  are  : — 

I.  Cephalic  version,  by  which  a  pelvic  presentation  or  trans- 
verse lie  is  changed  into  a  cephalic  presentation. 

II.  Podalic  version,  by  which  a  cephalic  presentation  or  trans- 
verse lie  is  changed  into  a  pelvic  presentation. 

Indications. — Version  is  possible  in  all  cases  in  which  the 
presenting  part  is  not  so  deeply  engaged  in  the  pelvis  that  it  is 
impossible  to  push  it  above  the  pelvic  brim.  It  is  indicated  in 
two  classes  of  cases  : — 

(i)  In  all  cases  of  transverse  lie  of  the  fcetus. 

(2)  In  certain  cases  of  longitudinal  lie,  in  which  the  presenta- 
tion of  the  opposite  pole  of  the  fcetus  is  likely  to  improve  the 
prognosis  for  either  the  mother  or  the  fcetus. 

As  a  head  presentation  offers  the  best  prospect  to  the  fcetus, 
cephalic  version  is  the  variety  of  version  always  to  be  chosen  in 
the  first  class  of  case,  and  it  is  only  if  the  head  cannot  be  induced 
to  engage  in  the  brim,  if  it  engages  in  a  faulty  attitude,  or  if  the 
immediate  delivery  of  the  fcetus  is  required  in  consequence  of 
some  complication,  as  a  prolapsed  cord,  that  podalic  version  is 
performed  instead. 

1005 


1006  OBSTETRICAL  OPERATIONS 

In  the  second  class  of  case,  cephalic  version  is  indicated  in 
pelvic  presentation  under  certain  circumstances,  and  to  these  we 
have  already  referred.*  Podalic  version,  on  the  other  hand,  is 
indicated  in  all  cases  of  brow  or  face  presentation  which  cannot 
be  changed  into  a  vertex  presentation,  and  in  posterior  fontanelle 
presentation,  provided  that  the  pelvis  is  sufficiently  large  to  allow 
the  passage  of  the  fetus.  It  is  also  indicated  in  certain  cases  of 
prolapse  of  the  cord,  of  placenta  praevia,  and  of  flattened  pelvis. 

Contra-indications.  —  The  performance  of  version  is  contra- 
indicated  under  the  following  conditions  : — 

(i)  If  it  is  obvious  that,  even  after  version,  the  foetus  cannot  be 
delivered  without  mutilation,  owing  to  its  size  or  to  the  presence 
of  pelvic  contraction. 

(2)  If  the  membranes  have  been  ruptured  for  a  considerable 
time,  and  the  retraction  ring  is  more  than  two  and  a  half  inches 
above  the  symphysis  pubis,  in  consequence  of  the  danger  of 
rupturing  the  uterus  during  the  necessary  manipulations. 

(3)  If  the  foetus  is  in  great  part  expelled  from  the  uterine  cavity, 
and  the  uterus  is  tightly  contracted  down  on  the  remainder.  The 
performance  of  version  necessitates  the  replacement  in  the  uterine 
cavity  of  the  already  expelled  portion  of  the  foetus,  and  this  can- 
not be  done  without  the  gravest  risk  of  uterine  rupture. 

There  are  three  methods  by  which  version  can  be  performed, 
namely : — 

I.  External  Version,  i.e.,  the  turning  of  the  foetus  by  external 
manipulations,  performed  with  the  hands  on  the  abdominal  wall. 

II.  Bi-polar  or  Combined  Version,  i.e.,  the  turning  of  the 
foetus  by  associated  external  and  internal  manipulations,  the 
former  performed  with  one  hand  on  the  abdominal  wall,  the  latter 
with  the  fingers  in  the  uterus. 

III.  Internal  Version,  i.e.,  the  turning  of  the  foetus  by  internal 
manipulations,  performed  with  the  whole  hand  in  the  uterus. 

In  choosing  the  method  to  be  adopted  in  any  particular  case, 
we  are  guided  by  the  general  principle  that  version  should  be 
performed  with  the  least  amount  of  intra-uterine  manipulation 
possible.  Consequently,  external  version  is  in  all  cases  the  method 
of  choice ;  if  it  cannot  be  performed  bi-polar  version  is  chosen ; 
and,  if  this  too  is  impossible,  internal  version  is  performed. 

External  Version. 

External  version  is  the  term  applied  to  the  turning  of  the  foetus 
by  manipulations  practised  through  the  abdominal  wall.  It  was 
first  introduced  by  Wigandf  in  1807,  and  though  for  many  years 
it  did  not  meet  with  the  recognition  it  deserved,  and  even  still  is 
not  the  method  selected  in  many  cases  in  which  it  is  practicable, 

*  Vide  Part  IV.,  Chap.  VI.,  p.  417. 

f  '  Ueber  Wendung  durch  aussere  Handgriffe,'  Hamburger  Med.  Mag.,  1807, 
vol.  i.,  p.  52. 


EXTERNAL   VERSION  1007 

it  constituted  a  great  advance  in  obstetrics  by  enabling  external 
to  be  substituted  for  internal  manipulations. 

Indications.— External  version  is  the  method  of  choice  in  all 
cases  in  which  it  is  necessary  to  alter  the  presentation  of  the 
foetus,  and  its  adoption  is  only  limited  by  necessity,  since  in  some 
cases,  it  is  impossible  to  perform  it.  For  its  performance,  the 
following  conditions  must  be  fulfilled  : — 

(1)  The  foetus  must  be  freely  movable  in  the  uterus. 

(2)  The  abdominal  walls  must  be  relaxed. 

(3)  It  must  be  possible  to  palpate  the  foetus  and  distinguish  its 
different  poles. 

Operation. — The  operation  of  external  version  is  not  a  painful  one, 
and,  consequently,  an  anaesthetic  is  not  necessary  on  this  account. 
In  many  cases,  however,  an  anaesthetic  may  be  necessary,  in  order 
to  obtain  complete  relaxation  of  the  abdominal  muscles,  as,  if 
they  are  contracted  and  rigid,  it  is  impossible  either  to  ascertain 
the  position  of  the  foetus  correctly,  or,  having  ascertained  the 
position,  to  alter  it.  As  soon  as  relaxation  of  the  walls  has  been 
obtained,  the  obstetrician  sits  on  the  couch  beside  the  patient 
in  the  position  adopted  when  performing  abdominal  palpation, 
and  ascertains  the  exact  position  of  the  foetus.  He  then  places 
one  hand  over  the  pelvic  pole,  the  other  over  the  cephalic  pole. 
If  he  desires  to  perform  cephalic  version,  he  gently  pushes  the 
cephalic  pole  with  the  corresponding  hand  in  whatever  direction 
brings  it  over  the  pelvic  brim  by  the  shortest  route.  If  the  head 
is  at  the  fundus,  and  each  route  is  equally  direct,  it  is  probably 
better  to  push  the  cephalic  pole  in  the  direction  of  the  foetal  back, 
the  pelvic  pole  in  the  opposite  direction,  as  in  this  way  flexion  of 
the  head  is  maintained.  The  choice  of  the  route  in  such  cases  is 
not,  however,  of  much  practical  importance.  If  we  desire  to  per- 
form podalic  version,  the  opposite  procedure  is  adopted,  and  the 
pelvic  pole  of  the  foetus  is  brought  over  the  pelvic  brim.  As  soon 
as  the  required  pole  has  been  brought  over  the  brim,  the  final 
step  consists  in  ensuring  that  it  remains  there  and  becomes  fixed 
in  the  brim,  as  it  is  often  inclined  to  slip  away  and  the  original 
presentation  to  recur.  For  this  reason,  there  is  very  little  use  in 
performing  external  version  until  labour  has  commenced.  Then, 
having  turned  the  foetus,  a  head  presentation  can  be  kept  in 
position  either  by  holding  it  over  the  brim  until  the  uterine  con- 
tractions fix  it,  or  by  applying  a  firm  abdominal  binder  supple- 
mented by  two  longitudinal  compresses,  one  at  each  side  of  the 
foetus,  to  prevent  the  latter  from  slipping  round.  If  these 
measures  do  not  succeed,  the  membranes  must  be  ruptured,  in 
order  to  enable  the  uterus  to  contract  down  on  the  body  of  the 
foetus  and  so  maintain  the  position  of  the  latter.  After  podalic 
version,  it  is  usually  customary  to  draw  down  a  foot  into  the 
vagina,  but  as  this  cannot  be  done  by  external  manipulation,  it 
must  be  considered  as  a  part  of  combined  or  internal  version 
rather  than  of  external  version. 


ioo8  OBSTETRICAL  OPERATIONS 


Bi-polar  or  Combined  Version. 

Bi-polar,  or  combined  external  and  internal  version  is  the  term 
applied  to  the  turning  of  the  foetus  by  associated  external  and 
internal  manipulations,  the  former  performed  with  one  hand  on 
the  abdominal  wall  as  in  external  version,  the  latter  with  two 
fingers  of  the  other  hand  in  the  uterus.  According  to  Winckel, 
it  was  first  recommended  by  Hohl*  in  1845,  but  it  has  come  to 
be  invariably  associated  with  the  name  of  Braxton  Hicks,  f  to 
whom  the  perfecting  and  popularising  of  the  operation  are  un- 
doubtedly due. 

Indications. — Bi-polar  version  is  indicated  in  all  cases  in  which 
external  version  is  impossible,  or  insufficient  in  consequence  of 
the  necessity  for  drawing  down  a  foot  into  the  vagina.  To 
perform  it,  the  same  conditions  must  be  fulfilled  as  for  external 
version,  with  the  addition  that  the  cervix  must  be  sufficiently 
dilated  to  admit  at  least  two  fingers. 

Operation. — In  almost  every  case  an  anaesthetic  is  necessary, 
as  the  introduction  of  the  hand  into  the  vagina  causes  pain,  and 
leads  to  straining  on  the  part  of  the  patient.  Such  straining 
prevents  the  proper  use  of  the  abdominal  hand,  and,  in  cases  in 
which  the  membranes  are  ruptured  during  the  operation,  may 
cause  the  forcing  down  of  the  cord  past  the  presenting  part.  The 
classical  operation  of  combined  version,  as  described  by  Braxton 
Hicks,  is  as  follows  : — The  patient  is  placed  in  the  dorsal  cross- 
bed  position,  and  the  hand  corresponding  to  the  side  at  which 
the  limbs  of  the  foetus  lie  is  introduced  as  far  as  is  necessary 
into  the  vagina,  while  the  other  hand  is  placed  externally  over 
the  breech  of  the  foetus.  The  external  hand  then  presses  gently 
but  firmly  on  the  breech  so  as  to  push  it  downwards  and  towards 
the  side  at  which  the  feet  are  situated.  As  it  recedes,  the  hand 
follows  it,  while,  at  the  same  time,  the  fingers  of  the  vaginal  hand 
introduced  through  the  cervix  push  the  head  upwards  and  towards 
the  opposite  side.  When  the  breech  has  been  pushed  down  to 
about  the  level  of  the  umbilicus,  the  head  will  have  cleared  the 
brim,  and  the  shoulder  will  be  opposite  the  uterine  orifice.  The 
shoulder  is  then  pushed  upwards  in  the  same  manner  as  was  the 
head,  and,  after  a  little  further  depression  of  the  breech  from 
without,  the  knee  will  be  found  within  reach  of  the  vaginal  finger 
and  can  be  hooked  down  until  the  foot  in  turn  comes  within 
reach.  The  operation  is  completed  by  drawing  the  foot  through 
the  os,  and  pushing  the  head  into  the  fundus  with  the  external 
hand. 

If  we  desire  to  perform  cephalic  version,  in  the  case  of  a  breech 
or  a  shoulder  presentation,  the  procedure  is  almost  identical  with 

*  Vortrage,  1845,  S.  189;  and  II.  Aufl.,  1862,  S.  789. 

t  'On  Combined  External  and  Internal  Version,'  Trans.  Obst.  Soc,  Lond., 
vol.  v.,  1863,  pp.  219-259,  and  Appendix,  pp.  265,  266. 


BI-POLAR  OR  COMBINED   VERSION 


1009 


that  just  described,  save  that  the  breech  or  shoulder,  as  the  case 
may  be,  is  pushed  upwards  with  the  vaginal  fingers  while  the 
head  is  pushed  downwards  from  without. 

It  has  been  customary  to  perform  bi-polar  podalic  version  at 
the  Rotunda  Hospital  for  some  years  in  a  slightly  different 
manner,  and  as  the  Rotunda  method  offers  certain  advan- 
tages, particularly  in  cases  of  placenta  prsevia,  we  shall  describe 
it.  The  patient  is  placed  in  the  dorsal  cross-bed  position,  and 
an  anaesthetic  is  administered.     The  exact  position  of  the  foetus 


Fig.  424. — Combined  Version. 

The  method  of  bringing  the  foot  through  a  small  os  by  pushing  the  cervix 
upwards  over  the  foot  with  the  fingers  in  the  vagina. 

is  then  ascertained  by  abdominal  palpation,  and  the  foetus  is 
turned  by  external  version  until  it  lies  transversely,  its  back 
towards  the  fundus,  and  its  limbs  in  the  lower  part  of  the  uterus. 
The  hand  corresponding  to  the  side  towards  which  the  breech  is 
turned  is  then  introduced  into  the  vagina,  i.e.,  the  left  hand  if  the 
breech  lies  on  the  mother's  right,  and  vice  versa,  and  the  opposite 
hand  is  placed  on  the  abdominal  wall  over  the  breech  of  the 
foetus.  Two  fingers  of  the  vaginal  hand  are  introduced  into  the 
uterus,  and  the  foot  is  felt  for,  seized,  and  drawn  down  into  the 

64 


ioio  OBSTETRICAL  OPERATIONS 

vagina.  If  the  foot  is  not  within  reach,  it  is  brought  nearer 
the  internal  os  by  pressure  with  the  external  hand  over  the 
breech.  It  sometimes  happens  that  the  uterine  orifice  may  be 
of  sufficient  size  to  admit  the  foot  alone  or  the  fingers  alone,  but 
will  not  accommodate  all  three.  In  such  cases,  we  have  found 
the  following  manipulation  of  use  : — Having  passed  the  fingers 
into  the  uterus,  and  caught  the  foot,  draw  the  latter  down  as  far 
as  possible,  and  in  such  a  position  that  the  toes  point  towards 
the  uterine  orifice.  Then,  draw  the  fingers  out  of  the  uterus, 
place  them  round  the  cervix  as  shown  in  Fig.  424,  and  with 
them  push  the  cervix  upwards  over  the  foot,  while  at  the  same 
time  the  external  hand  makes  the  foot  descend  by  pressure  upon 
the  breech.  In  this  way,  the  toes  can  often  be  brought  through 
the  uterine  orifice,  and  can  then  be  caught  by  the  vaginal  fingers 
and  the  remainder  of  the  foot  brought  down.  Lastly,  the  head  is 
pushed  up  to  the  fundus  with  the  external  hand. 

Internal  Version. 

Internal  version  is  the  term  usually  applied  to  the  turning  of 
the  foetus  by  internal  manipulation  performed  by  the  whole  hand 
introduced  into  the  uterus.  The  term  '  internal  version  '  is  to  some 
extent  a  misnomer,  inasmuch  as  in  no  case  is  the  internal  hand 
alone  used.  In  reality,  internal  version,  so  called,  is  a  combined 
external  and  internal  version,  and  differs  from  the  method  that 
has  been  just  described  in  that  the  whole  hand  is  introduced  into 
the  uterus  instead  of  two  fingers,  the  use  of  the  external  hand 
being  identical  in  both  methods.  For  this  reason,  the  terms 
applied  to  the  two  methods  by  Winckel  are  preferable  to  those 
in  common  use,  i.e.,  for  bi-polar  version — 'combined  indirect 
version,'  and  for  internal  version — '  combined  direct  version.' 
As,  however,  the  term  internal  version  has  come  to  be  generally 
recognised  and  its  meaning  understood,  we  prefer  to  make  use 
of  it. 

Indications. — Internal  version  is  indicated  in  all  cases  in  which 
external  or  bi-polar  version  is  impossible.  For  its  performance, 
one  condition  is  necessary  in  addition  to  the  general  conditions 
already  given,  namely,  that  the  uterine  orifice  is  sufficiently 
dilated  to  admit  the  entire  hand.  Theoretically  both  cephalic 
and  podalic  version  can  be  performed  by  internal  version, 
and  both  D'Outrepont*  and  Busch  have  described  methods  of 
performing  cephalic  version  in  this  way,  but,  at  the  present  time, 
it  is  generally  recognised  that  if  labour  has  reached  such  a  stage 
that  it  is  possible  to  introduce  the  entire  hand  into  the  uterus,  it 
is  preferable  to  perform  podalic  rather  than  cephalic  version,  as 
the  former  is  more  easy  of  performance,  and  can,  if  necessary, 
be  at  once  followed  by  extraction. 

Operation. — For  the  performance  of  internal  version  the  patient 
*  '  Abh.  und  Beitrage,'  Wurzburg,  1817,  Theil  I.,  p.  69 


INTERNAL   VERSION  ion 

may  be  placed  on  her  left  side  in  the  usual  obstetrical  position, 
or  on  her  back  in  the  cross-bed  position.  We  consider  that  the 
latter  position  is  the  better  of  the  two,  as  it  enables  more  use 
to  be  made  of  the  abdominal  hand,  and  so  we  shall  describe 
how  the  operation  is  performed  when  the  patient  is  in  that 
position. 


Fig.  425. — Internal  Version.     Seizing  a  Foot. 


The  first  step  in  the  operation,  as  in  all  methods  of  perform 
ing  version,  consists  in  ascertaining  as  carefully  as  possible, 
by  abdominal  palpation  and  vaginal  examination,  the  exact 
presentation  and  position  of  the  foetus.  The  second  step  con- 
sists in  introducing  a  hand  into  the  uterus,  seizing  a  foot,  and 
drawing    it   downwards.      The    final    step    consists    in    pushing 

64 — 2 


ioi2  OBSTETRICAL  OPERATIONS 

the  head  into  the  fundus  of  the  uterus,  and  at  the  same  time 
drawing  down  the  foot  more  deeply  into  the  vagina.  The 
first  step  calls  for  no  comment  save  that  the  choice  of  the 
hand  to  be  introduced  into  the  uterus  depends  on  whether  the 
head  or  the  shoulder  presents. 

The  correct  method  of  carrying  out  the  second  step  has 
given  rise  to  endless  discussion,  and  may  be  regarded  as  one  of 
the  hereditary  moot  points  of  obstetrics.  In  some  works,  pages 
are  devoted  to  a  discussion  on  the  hand  which  should  be 
introduced  into  the  uterus,  and  the  foot  which  should  be  pulled 
upon.  Inasmuch  as  it  appears  that  the  most  distinguished 
obstetricians  hold  diametrically  opposite  opinions  on  these  points, 
and  as  each  contends  that  the  method  he  recommends  offers 
advantages  over  all  others,  it  would  appear  that  there  cannot 
be  a  very  great  difference  between  the  methods.  This  view  is 
supported  by  our  clinical  experience,  which  has  taught  us  that 
the  best  hand  to  introduce  is  the  one  which  naturally  adapts 
itself  to  the  position  in  which  the  feet  of  the  foetus  are  placed, 
and  that  the  best  foot  to  draw  down  is  the  foot  most  easily 
reached.  Thus,  in  a  transverse  presentation,  we,  personally, 
use  the  right  hand  when  the  lower  limbs  lie  on  the  right  side 
of  the  mother,  and  the  left  hand  when  they  lie  on  the  left 
side.  In  a  head  presentation  we  use  the  right  hand  in  all 
positions  of  the  foetus  save  when  the  limbs  are  to  the  right  and 
in  front.  In  such  a  case,  the  left  hand  is  more  suitable.  A 
left-handed  operator  will  reverse  this  procedure,  and  in  a  head 
presentation  use  the  left  hand  whenever  possible.  Other  operators 
again  will  use  the  hand  corresponding  to  the  position  of  the 
limbs — the  right  hand  if  the  limbs  are  on  the  patient's  left,  the 
left  hand  if  the  limbs  are  on  the  patient's  right.  The  selection  of 
the  hand  is  of  little  importance,  save  that  it  is  wise  to  use  the 
hand  that  gets  into  the  required  position  most  easily  and  with  the 
least  cramp. 

Still  more  divergent  opinions  have  been  expressed  with  regard 
to  the  foot  that  is  to  be  drawn  down.  Sir  J.  Simpson,  Barnes, 
Playfair,  and  almost  all  the  older  English  writers,  recommend 
that  in  transverse  presentation  the  upper  foot,  i.e.,  the  foot 
belonging  to  the  opposite  side  to  the  presenting  shoulder,  should 
be  seized  [v.  Fig.  425),  on  the  ground  that  by  pulling  upon  it  a 
more  complete  rotation  of  the  foetus  round  its  longitudinal  axis 
can  be  produced.  On  the  other  hand,  other  writers,  notably 
Winckel  and  Galabin,  recommend  that  the  lower  foot  be  seized, 
on  the  ground  that  the  rotation  that  is  thus  caused  is  less  com- 
plicated. As  we  have  already  said,  we  consider  that  there  is  no 
special  advantage  to  be  gained  by  selecting  either  one  or  the 
other,  and  that  the  correct  foot  to  seize  is  the  one  that  comes  first 
to  our  hand. 

The  final  step  of  the  operation — the  pushing  up  of  the  head  to 
the  fundus  of  the  uterus — is  a  most  essential  one.    The  immediate 


INTERNAL    VERSION 


1013 


result  of  drawing  the  foot  down  is  that  the  presentation  becomes, 
in  most  cases,  the  complex  one  of  a  foot  and  a  head,  or  some- 
times of  a  foot,  a  hand,  and  a  head  (v.  Fig.  426),  and,  if  this  was 
allowed  to  persist,  delivery  would  be  impossible.  Accordingly, 
the  head  must  be  pushed  up  to  the  fundus,  usually  with  the 
external  hand,  and  a  longitudinal  he  of  the  foetus  thus  obtained. 
If  the  lateral  position  instead  of  the  dorsal  is  chosen  for  the 


Fig.  426. — Internal  Version. 

The  foot  is  drawn  into  the  vagina  with  the  ringers  of  the  right  hand, 
while  the  left  hand  pushes  the  head  towards  the  fundus. 


operation,  the  patient  is  placed  upon  the  same  side  as  that  to 
which  the  feet  are  turned,  whatever  may  be  the  presentation  of 
the  foetus,  and  the  opposite  hand  is  introduced,  i.e.,  if  the  feet 
are  on  the  left  side  of  the  uterus,  the  patient  lies  on  her  left  side, 
and  the  operator  introduces  the  right  hand. 

We  must  now  describe  the  complete  operation  in  the  case  of  a 
transverse  lie  of  the  foetus  in  a  little  more  detail.  The  patient  is 
anaesthetised  and  placed  in  the  dorsal  cross-bed  position.     The 


IOI4 


OBSTETRICAL  OPERATIONS 


operator   sits   on   a   low   stool  in   front  of  her,   and   introduces 
the  hand  which  he  considers  most  suitable,  taking  care  to  keep 


! 


Fig.  427. — Internal  Version. 

The  right  hand  outside  the  vagina  draws  down  the  foot  by  means  of  a  fillet 
applied  round  the  ankle,  while  the  fingers  of  the  left  hand  in  the  vagina 
push  the  head  upwards. 

inside  the  amniotic  sac.     The  use  of  rubber  gloves  is  a  distinct 
advantage,    as    it    ensures   asepsis,    and,    if    they    are   kept    wet 


INTERNAL   VERSION  1015 

in  lysol  solution,  makes  the  hand  smoother  and  diminishes 
friction.  The  operator  then  seizes  the  foot  that  first  offers 
itself,  and  draws  it  down  towards  the  uterine  orifice,  while  at 
the  same  time  by  pressure  with  the  external  hand  applied  over 
the  abdominal  wall  the  breech  is  pushed  upwards  and  towards 
the  side  at  which  the  feet  lay  (v.  Fig.  425).  By  this  means,  the 
fcetus  is  brought  into  the  position  shown  in  Fig.  426,  and  the 
foot  is  brought  into  the  vagina.  The  external  hand  is  then 
placed  on  the  foetal  head  and  pushes  the  latter  directly  upwards, 
while,  at  the  same  time,  the  foot  is  drawn  more  deeply  into  the 
pelvis.  As  soon  as  the  head  has  been  pushed  into  the  fundus, 
version  is  complete. 

If  the  case  is  one  of  neglected  shoulder  presentation,  the  per- 
formance of  internal  version  may  be  most  difficult  or  even 
impossible,  owing  to  the  difficulty  of  effecting  the  final  step  of 
the  operation  and  pushing  the  head  up  to  the  fundus.  If  the 
method  of  doing  so,  which  we  have  just  described,  fails,  the  plan 
shown  in  Fig.  427  may  be  adopted  with  success.  A  fillet  of 
iodoform  or  sterilised  gauze  is  passed  over  the  foot  which  has 
been  drawn  down  into  the  vagina  and  fixed  round  the  ankle  by  a 
clove  hitch.  The  ends  of  the  fillet  are  brought  outside  the  vagina 
and  held  in  the  right  hand,  so  that,  by  applying  traction  to  them, 
the  foot  can  be  brought  down  without  the  necessity  for  intro- 
ducing the  hand  into  the  vagina.  This  leaves  the  latter  free  for 
the  introduction  of  the  left  hand,  and,  with  the  fingers,  the  head 
is  pushed  upwards  from  below,  while  at  the  same  time  an  assistant 
also  presses  it  up  from  outside.  In  this  way,  we  have  three  forces 
uniting  to  complete  version,  the  vaginal  foot  is  being  drawn  down 
by  the  right  hand,  the  head  is  being  pushed  up  from  the  vagina 
with  the  fingers  of  the  left  hand,  and  is  also  being  pushed  upwards 
externally  by  the  hand  of  the  assistant. 

In  most  cases  of  neglected  shoulder  presentation,  the  hand 
corresponding  to  the  presenting  shoulder  has  prolapsed  into  the 
vagina.  In  these  cases,  a  gauze  fillet  should  be  slipped  over  the 
wrist,  in  order  that  subsequently,  during  the  expulsion  of  the 
fcetus,  the  arm  may  be  kept  by  the  side  of  the  body  and  prevented 
from  slipping  upwards  beside  the  head.  It  is  unnecessary  to 
make  any  efforts  to  replace  the  arm  prior  to  the  performance  of 
version.  The  hand  may  be  introduced  into  the  uterus  beside  it, 
and  then,  as  the  breech  is  brought  down  and  the  head  pushed 
up,  the  arm  will  be  drawn  upwards  by  the  rotation  of  the  foetal 
body. 


ioi6  OBSTETRICAL  OPERATIONS 

THE    EXTRACTION    OF    THE    FOETUS    IN    PELVIC 
PRESENTATION 

In  the  following  sections,  we  shall  discuss  the  delivery  of 
the  foetus  when  it  presents  by  the  pelvic  pole,  and  when  the 
conditions  of  the  case  call  for  assistance  to  the  natural  efforts. 
These  procedures  are  analogous  to  the  delivery  of  the  foetus  by 
the  forceps  when  the  cephalic  pole  presents. 

Indications. — The  indications  for  extraction  in  pelvic  presenta- 
tion are  almost  identical  with  those  already  given  for  extraction 
by  the  forceps  in  cephalic  presentation,  and  may  be  divided  into 
the  following  groups  :— 

(i)  Indications  that  the  life  of  the  foetus  is  in  danger,  as  shown 
by  the  rising  of  the  rate  of  the  foetal  heart  above  160  or  its  falling 
below  1 20  ;  tumultuous  movements  of  the  foetus  ;  and  the  coming 
away  of  meconium  while  the  breech  is  still  above  the  brim. 

(2)  Certain  cases  of  prolapse  or  presentation  of  the  cord. 

(3)  The  appearance  of  the  symptoms  of  threatened  rupture  of 
the  uterus. 

(4)  The  occurrence  of  complications  which  threaten  the  life  of 
the  mother,  such  as  certain  cases  of  ante-partum  haemorrhage,  or 
eclampsia. 

(5)  The  presence  of  maternal  organic  disease  necessitating  the 
shortening  of  labour,  as  in  certain  cases  of  cardiac,  renal  and 
pulmonary  disease. 

(6)  Failure  of  the  natural  efforts  to  effect  delivery  in  consequence 
of  uterine  inertia,  obstruction  to  the  passage  of  the  breech  at  the 
pelvic  brim,  or  impaction  of  the  breech  in  the  pelvic  cavity. 

In  order  that  extraction  may  be  successfully  accomplished, 
the  pelvis  and  vaginal  canal  must  be  of  sufficient  size,  to  allow 
the  passage  of  the  foetus,  if  necessary,  after  reduction  by  crushing 
or  embryotomy ;  and  the  cervix  must  be  sufficiently  dilated. 

Operation. — The  extraction  of  the  foetus  in  a  pelvic  presentation 
may  be  divided  into  three  distinct  procedures ; — The  extraction 
of  the  pelvic  pole ;  the  liberation  and  delivery  of  the  arms ;  and 
the  delivery  of  the  after-coming  head. 

If  we  are  compelled  to  adopt  the  first  procedure,  the  others  are 
usually  also  necessary,  and,  sometimes,  even  when  the  pelvic  pole 
of  the  foetus  has  been  expelled  spontaneously,  the  second  or  third 
procedure  or  both  have  to  be  adopted. 

The  Extraction  of  the  Pelvic  Pole. — The  patient  is  placed  in  the 
dorsal  cross-bed  position.  If  the  pelvis  and  the  vagina  are  roomy, 
or  if  the  patient  is  a  multipara,  and  if  the  breech  is  not  impacted, 
the  administration  of  an  anaesthetic  is  not  necessary,  but,  as  a 
rule,  it  is  advisable,  and,  if  the  case  presents  any  difficulty,  is 
essential.  The  first  step  of  the  operation  is  to  ascertain  the 
part  of  the  child  on  which  traction  can  be  made,  and  the 
means  by  which  it  can   be  best  applied,  in  the  particular  case 


THE  EXTRACTION  OE  THE  PELVIC  POLE 


1017 


with  which  we  are  dealing.  Traction  can  be  best  applied  by 
pulling  with  the  hands  on  one  or  both  of  the  legs  of  the  foetus, 
and  this  course  is  usually  possible  if  the  breech  is  not  impacted 
in  the  pelvic  cavity.  If  the  breech  is  so  impacted,  traction  can 
be  best  applied  by  the  fingers  hooked  into  one  or  both  groins,  or 


Fig.  428. — The  Extraction  of  the  Pelvic  Pole  of  the  Fcetus. 
Bringing  down  a  Leg. 

The  fingers  of  the  left  hand  in  the  uterus  flex  the  leg  by  pressure  below 

the  knee. 

by  a  gauze  fillet  passed  over  a  groin,  and  pulled  on  with  the 
hands  outside  the  vagina.  Accordingly,  in  all  cases,  if  the  foot 
is  not  already  presenting,  our  first  object  is  to  ascertain  whether 
it  is  possible  to  bring  it  down  into  the  vagina.  This  can  always 
be  done  when  the  breech  is  still  at  the  pelvic  brim,  but,  after  it 


1018  OBSTETRICAL  OPERATIONS 

has  descended  into  the  pelvis,  it  is  rarely  possible.  To  bring 
down  the  foot,  the  hand  corresponding  to  the  side  at  which  the 
feet  lie,  i.e.,  the  left  hand  if  the  feet  are  on  the  mother's  right  side, 
and  vice  versa,  is  passed  into  the  vagina,  and  the  fingers  pushed 


Fig.  429.— The  Extraction  of  the  Pelvic  Pole  of  the  Fcetus. 
Bringing  down  a  Leg. 

The  fingers  of  the  left  hand  in  the  vagina  draw  the  foot  through  the 
uterine  orifice. 

upwards  between  the  thigh  and  the  uterus  as  shown  in  Fig.  428. 
If  the  pelvic  presentation  is  complete,  i.e.,  if  the  feet  lie  beside 
the  thigh,  the  foot  is  at  once  reached  and  can  be  seized  and  drawn 
downwards.     If,  however,  the  legs  are  extended,  then  it  is  neces- 


THE  EXTRACTION  OF  THE  PELVIC  POLE 


1019 


sary  to  push  the  fingers  farther  upwards  into  the  uterus  until  the 
lower  leg  is   reached.     Then,  two   fingers  are  hooked  over  the 


Fig.  430. — The  Extraction  of  the  Pelvic  Pole  of  the  Foztus. 
Traction  on  the  Leg. 


anterior  aspect  of  the  leg,  and  by  gentle  pressure  the  leg  is  flexed 
at  the  knee  and  the  foot  brought  into  the  neighbourhood  of  the 


io2o  OBSTETRICAL  OPERATIONS 

pelvic  brim.  The  foot  itself  can  be  then  caught  in  the  fingers 
and  drawn  downwards  as  shown  in  Fig.  429.  This  procedure  has 
the  double  effect  of  bringing  the  foot  down  and  so  enabling  traction 
to  be  made  upon  it,  and  of  lessening  the  size  of  the  presenting 
breech  by  the  thickness  of  the  thigh.  Traction  is  then  made  on  the 
foot,  at  first  in  the  axis  of  the  pelvic  brim,  and  later,  as  the  breech 
descends,  in  such  a  direction  as  to  follow  the  curve  of  the  pelvis 
(v.  Fig.  430).  If  the  breech  refuses  to  advance,  the  hand  must 
be  again  introduced  and  the  other  foot  brought  down,  so  as  to 
still  further  reduce  the  size  of  the  presenting  part.  If  the  skin 
of  the  foot  is  so  slippery  that  a  firm  grip  cannot  be  obtained,  it  is 
well  to  cover  it  with  a  soft  cloth,  and  this  also  serves  to  prevent 
the  occurrence  of  abrasions. 

If  the  breech  has  entered  the  pelvic  cavity,  it  is  seldom  possible 
to  bring  down  the  foot,  and,  consequently,  we  must  resort  to  other 
means  of  applying  traction.  This  is  most  readily  done  by  hooking 
the  fingers  into  the  groins  and  pulling  upon  the  latter.  At  first, 
the  anterior  groin  alone  is  within  reach,  and  the  index-finger  or 
the  index  and  middle  fingers  passed  upwards  between  the  breech 
and  the  anterior  pelvic  wall  are  hooked  over  it,  and  traction 
applied  (v.  Fig.  431).  The  amount  of  force  that  can  be  applied 
in  this  way  is  not  very  great,  but  still  is  sometimes  sufficient. 
The  strength  of  the  fingers  can  be  considerably  increased  by 
grasping  the  wrist  of  the  same  hand  firmly  with  the  other  hand, 
as  an  additional  support  is  thus  given  to  the  flexor  tendons.  If 
the  anterior  groin  is  drawn  down  a  little  way,  it  will  be  then  found 
possible  to  pass  the  fingers  in  a  similar  manner  into  the  posterior 
groin,  and  to  draw  it  down.  In  this  manner,  by  alternate  traction 
on  each  groin,  the  breech  is  brought  down  to  the  pelvic  floor,  and, 
as  soon  as  this  is  done,  it  will  be  perhaps  possible  to  get  a  finger 
into  both  groins  simultaneously  (v.  Fig.  432).  In  all  cases,  care 
must  be  taken  that  the  finger  is  placed  in  the  angle  of  the  groin, 
and  traction  made  directly  down  into  the  angle  in  such  a  manner 
as  to  avoid  any  outward  pull  on  the  femur,  as  such  a  force  would 
be  very  likely  to  cause  the  fracture  of  the  latter. 

If  the  breech  is  so  firmly  impacted  in  the  pelvis  that  it  resists 
these  efforts,  some  method  must  be  adopted  by  which  stronger 
traction  can  be  applied,  There  are  various  methods  of  doing 
this,  but  their  adoption  means  a  greatly  increased  risk  of  injury 
to  the  fcetus.  The  safest  method  consists  in  passing  a  fillet  of 
gauze  over  the  groin,  and  bringing  the  ends  outside  the  vagina,  but 
the  application  of  the  fillet  is  often  a  matter  of  difficulty.  The 
easiest  manner  of  applying  it  is  as  follows  : — Take  a  small  piece 
of  double  gauze  about  eighteen  inches  long  and  two  inches  wide, 
and  rolled  like  a  bandage.  The  free  end  of  this  roll  is  held  in  the 
left  hand,  and  the  roll  itself  is  pushed  upwards  between  the  thigh 
and  the  anterior  pelvic  wall,  in  such  a  manner  that  as  it  advances 
it  unrolls.  As  soon  as  it  has  been  pushed  above  the  angle  of  the 
groin,  it  is  pushed  inwards  across  the  latter  until  it  comes  to 


THE  EXTRACTION  OE  THE  PELVIC  POLE  1021 

lie  between  the  thighs.  Then,  the  fingers  are  pushed  upwards 
from  below  between  the  thighs,  and  the  roll  of  gauze  caught  and 
drawn  downwards.  If  the  first  piece  of  gauze  which  was  intro- 
duced is  not  sufficiently  strong,  a  stouter  piece  can  be  knotted  to 
one  end  of  it  and  drawn  over  the  groin.     Traction  is  then  applied 


Fig.  431. — The  Extraction  of  the  Pelvic  Pole  of  the  Fcetus  by 
Traction  on  the  Anterior  Groin. 

The  finger  of  the  left  hand  hooked  into  the  anterior  groin  endeavours  to 
pull  the  latter  down. 


to  the  ends  of  the  gauze,  taking  care  that  it  is  made  as  shown  in 
Fig.  433,  that  the  gauze  comes  well  down  into  the  angle,  and 
that  there  is  no  outward  strain  on  the  femur.  Another  method 
of  applying  the  gauze  consists  in  using  a  catheter  as  a  porte-fillet. 


OBSTETRICAL  OPERATIONS 


Take  an  ordinary  No.  10  or  12  gum-elastic  catheter  with  a  strong 
stylette,  thread  it  with  a  piece  of  stout  silk  or  twine,  and  bend  its 
upper  end  into  a  semicircle  corresponding  in  size  to  the  circum- 
ference of  the  thigh.     Then,  slip  the  catheter  upwards  anteriorly 


Fig.  432. — The  Extraction  of  the  Pelvic  Pole  of  the  Fcstus  by 
Traction  on  Both  Groins. 

The  breech  has  been  brought  down  to  the  pelvic  outlet,  and  an  index 
finger  is  hooked  into  each  groin. 

until  the  tip  can  be  guided  over  the  groin,  and  lies  somewhere 
near  the  symphysis  of  the  foetus.     Hold  the  stylette  by  the  ring, 


THE  EXTRACTION  OF  THE  PELVIC  POLE 


1023 


and  push  the  catheter  itself  gently  upwards,  and  the  curve  which 
has  been  given  to  the  stylette  will  guide  the  tip  of  the  catheter 
downwards  between  the  thighs,  where  it  can  be  reached  with  the 
fingers.     The  end  of  the  silk  is  caught  and  knotted  to  a  piece  of 


Fig.  433. — The  Extraction  of  the  Pelvic  Pole  of  the  Fcetus  by 
means  of  a  gauze  flllet  applied  over  the  anterior  groin. 


gauze,  which  is  then  drawn  up  to  the  eye  of  the  catheter  by 
means  of  the  silk.  The  catheter  and  stylette  are  next  gently 
withdrawn,  and,  at  the  same  time,  the  gauze  is  carried  over  the 
groin. 


io24  OBSTETRICAL  OPERATIONS 

If  the  breech  cannot  be  extracted  by  these  measures,  it  is  most 
unlikely  that  the  foetus  can  be  delivered  without  sustaining  serious 
and  perhaps  fatal  injuries,  and,  consequently,  the  methods  which 
we  are  about  to  describe  should  not  be  adopted  unless  the 
foetus  is  dead,  or  all  other  means  of  extraction  have  failed.  These 
methods  are  the  use  of  the  blunt  hook,  the  application  of  the 
forceps,  or  the  cephalotribe.  The  blunt  hook  is  applied  usually 
over  the  anterior  groin,  and  traction  is  then  applied  as  in  the 
case  of  the  fillet.  For  the  foetus,  it  is  always  a  dangerous  instru- 
ment, as  the  point  of  the  hook  may  cause  considerable  abrasion 
of  the  skin,  or  may  even  open  the  femoral  vessels.  Further,  in 
the  hands  of  an  unskilful  operator,  it  may  cause  injury  to  the 
maternal  soft  parts.  We  have  ourselves  no  experience  of  its  use, 
but  it  does  not  seem  to  offer  any  advantages  over  the  fillet,  while 
it  is  very  much  more  dangerous.  If  the  fillet  cannot  be  applied, 
the  blunt  hook  might  be  tried.  It  is,  however,  an  instrument  which 
is  very  seldom  carried  in  the  modern  obstetrical  bag.  If  it  is 
used,  care  must  be  taken  to  bring  the  point  of  the  hook  down 
between  the  thighs  in  such  a  manner  that  if  presses  as  little 
as  possible  on  the  foetal  tissues,  and  is  not  in  contact  with  the 
maternal  soft  parts.  The  forceps  has  been  recommended  by 
many  writers  as  a  means  of  effecting  delivery  in  these  cases,  and 
notably  by  Lusk,  but  at  the  present  time  there  are  not  many 
advocates  of  its  use.  It  possesses  the  disadvantage  that  it  is  ill 
adapted  for  seizing  the  breech,  and  that  consequently  it  must  be 
screwed  up  so  tightly,  to  prevent  it  from  slipping,  that  it  will 
almost  certainly  injure  the  foetus.  If,  however,  all  other  means 
have  failed,  and  the  life  of  the  foetus  cannot  be  saved,  it  may 
enable  delivery  to  be  effected.  In  such  cases,  it  is  applied  as 
nearly  as  possible  over  the  thighs  of  the  foetus.  The  last  instru- 
ment, to  which  we  may  be  compelled  to  resort  in  cases  of  marked 
disproportion  between  the  size  of  the  breech  and  the  pelvis,  is  the 
cranioclast.  It  is  to  be  applied  in  relation  to  the  bi-trochanteric 
diameter  of  the  pelvis,  and  by  crushing  and  reducing  the  size  of 
the  latter  may  enable  delivery  to  be  effected. 

Whatever  method  of  extracting  the  breech  is  adopted,  it  must 
be  supplemented  by  firm  pressure  over  the  uterus,  made  in  such 
a  direction  as  to  push  the  foetus  downwards  into  the  pelvic  brim. 

The  Liberation  and  Delivery  of  the  Arms. — In  all  cases  in 
which  the  arms  become  extended,  and,  leaving  their  normal 
position,  pass  upwards  beside  the  head,  it  is  necessary  to  bring 
them  down  again  before  proceeding  to  deliver  the  head.  The 
bringing  down  of  extended  arms  is  always  a  delicate  operation. 
In  most  cases,  there  has  been  already  some  delay,  and  it  is  now 
necessary  to  complete  delivery  as  rapidly  as  possible,  or  the  life 
of  the  foetus  will  be  lost ;  but,  if  in  our  efforts  to  save  time  any 
manipulation  is  performed  in  an  improper  manner,  there  is  a 
great  risk  of  fracturing  the  humerus  or  the  clavicle.  In  some 
cases,  indeed,  it  may  be  impossible  to  avoid  such  an  accident, 


THE  LIBERATION  AND  DELIVERY  OF  THE  ARMS         [025 

but  in  the  greater  proportion  of  cases,  skill  and  knowledge  of  the 
manipulations  necessary  will  prevent  its  occurrence.  The  all- 
important  point  to  remember  is  that  pressure  must  be  so  made 
that  the  arm  can  respond  to  it  by  the  natural  movements  per- 
mitted by  the  joints.  A  common  mistake  consists  in  pulling  upon 
the  centre  of  the  humerus  in  such  a  direction  that  the  arm  can 
only  respond  to  the  force  applied  by  fracture  at  the  point  of 
pressure.  The  arm  may  lie  in  one  of  several  positions.  It  may 
be  completely  extended  at  both  shoulder  and  elbow,  it  may  be 
extended  at  the  shoulder  alone,  or  it  may  lie  in  front  of  the  face 
or  behind  the  head.  The  two  most  common  positions  are  first 
where  the  arm  is  completely  extended  and  lies  straight  upwards 
beside  the  head,  and  secondly  where  the  whole  arm  is  raised 
until  the  elbow  lies  at  the  level  of  the  face,  but  the  forearm  is 
still  flexed  at  the  elbow.  As  the  fcetus  lies  in  the  pelvis,  the  bis- 
acromial  diameter  more  or  less  closely  corresponds  to  one  oblique 
diameter  of  the  pelvis,  and,  consequently,  one  arm  is  posterior  and 
in  relation  to  the  sacrum,  the  other  arm  anterior  and  in  relation 
to  the  pubes.  The  posterior  is  higher  than  the  anterior,  but 
there  is  sufficient  room  for  the  operator's  hand  in  the  hollow  of 
the  sacrum,  and  there  is  but  little  room  behind  the  pubes.  More- 
over, when  the  patient  is  in  the  dorsal  position  it  is  easier  to  pass 
the  hand  into  the  vagina  along  the  curve  of  the  sacrum,  than 
behind  the  symphysis.  Accordingly,  in  almost  every  case  it  is 
easier  first  to  bring  down  the  posterior  arm. 

This  procedure  is  carried  out  as  follows  : — The  obstetrician 
stands  or  sits  in  front  of  the  patient,  and  passes  the  hand,  which 
corresponds  to  the  side  towards  which  the  face  of  the  child  is 
turned,  into  the  vagina.  The  fingers  are  slipped  upwards  along 
the  thorax  until  the  posterior  shoulder  is  reached,  and  then 
along  the  humerus  until  they  come  to  the  elbow  (v.  Fig.  434). 
If  the  arm  is  completely  extended  and  stands  vertically  upwards 
beside  the  head,  the  tips  of  the  fingers  press  upon  the  extensor 
surface  of  the  forearm  below  the  elbow  in  such  a  manner  as  to 
cause  the  forearm  to  flex,  while  at  the  same  time  the  entire  arm 
is  swept  across  the  face  by  gently  carrying  it  forwards  and  down- 
wards. In  some  cases,  the  arm  will  come  down  most  easily  with 
the  angle  of  the  elbow  pointing  downwards  and  inwards,  in  other 
cases  it  will  come  most  easily  with  the  angle  pointing  upwards 
and  outwards.  If  the  arm  is  only  partially  raised,  and  is  flexed 
at  the  elbow,  it  can  easily  be  brought  down  by  hooking  one  or 
two  fingers  into  the  angle  of  the  elbow  and  drawing  the  latter 
downwards  over  the  chest. 

The  anterior  arm  must  be  next  brought  down.  This  can  be 
done  in  two  ways,  either  the  arm  can  be  brought  down  from  the 
position  it  occupies  behind  the  pubes,  that  is  as  an  anterior  arm, 
or  the  body  of  the  fcetus  can  be  so  rotated  that  the  arm  comes 
to  lie  posteriorly,  when  it  can  be  brought  down  in  the  manner 
just  described.      The  difficulty  of  reaching  the  arm  when  it  lies 

65 


1026 


OBSTETRICAL  OPERATIONS 


anteriorly  has  been  already  mentioned.  It  can  to  a  certain  extent 
be  overcome  by  a  manipulation  which  we  shall  presently  describe, 
but  even  then  the  proceeding  is  not  easy.  There  is  no  difficulty 
in  rotating  the  foetus  until  the  anterior  arm  becomes  posterior, 
but  there  are  two  objections.     In  the  first  place,  if  the  head  of 


Xv 


Fig.  434. — The  Liberation  of  the  Arms  in  Pelvic  Presentation. 

The   body   of  the   foetus   is   drawn   slightly   to    the   left,    and  the   operator 
passes   his   right    hand   into   the    uterus   to    bring   down  the   posterior 


the  foetus  is  fixed  it  is  not  safe  to  rotate  the  body  through  more 
than  a  quarter  of  a  circle,  as  by  so  doing  the  ligaments  of  the 
articulations  of  the  axis  and  the  atlas  vertebra?  may  be  ruptured, 


THE  LIBERATION  AND  DELIVERY  OF  THE  ARMS 


1027 


and  the  spinal  cord  compressed  with  a  fatal  result.  If,  however, 
the  head  of  the  fcetus  is  above  the  brim  and  is  free  to  move,  the 
body  may  be  safely  rotated  to  any  desired  extent.  In  the  next 
place,  if  the  rotation  is  so  made  that  the  anterior  shoulder  is 
carried  in  the  direction  of  the  chest  of  the  fcetus,  the  arm  may 
be  carried  behind  the  head,  and  the  case  made  more  difficult 


Fig.  435. — The  Nuchal  Position  of  the  Arm. 

than  it  was  before.  Rotation  in  this  direction  is  unnecessary  if 
the  fcetus  lies  with  its  back  directed  posteriorly,  i.e.,  in  either  the 
third  or  fourth  position  of  Naegele,  as  then  the  anterior  shoulder 
can  be  made  posterior  by  rotating  the  body  through  a  quarter  of 
a  circle  in  such  a  direction  that  the  anterior  shoulder  moves  in  the 
direction  of  the  fcetal  back.  Also,  when  the  back  lies  anteriorly, 
and  the  head  is  free  above  the  brim,  a  similar  result  can  be 

65—2 


1028  OBSTETRICAL  OPERATIONS 

obtained  by  rotating  the  body  in  the  same  direction  but  through 
half  a  circle.  Such  a  rotation  will  further  facilitate  matters  by 
bringing  the  arm  more  directly  in  front  of  the  face  of  the  foetus. 
If,  however,  the  head  is  not  free  to  move,  the  long  rotation  cannot 
be  performed,  and  consequently  we  must  make  a  choice  between 
performing  the  short  rotation  and  perhaps  carrying  the  arm 
behind  the  head  of  the  foetus,  or  bringing  down  the  arm  as  an 
anterior  arm.  Under  such  circumstances,  perhaps  the  best  rule 
to  adopt  is  to  perform  the  short  rotation  in  the  direction  of  the 
back  when  the  latter  lies  posteriorly,  and  then  to  bring  the  arm 
down  as  a  posterior  arm  ;  and,  if  this  cannot  be  done,  to  bring  the 
arm  down  as  an  anterior  arm.  To  do  this,  draw  the  body  of  the 
child  as  far  backwards  as  possible  and  pass  as  much  as  is  neces- 
sary of  the  hand,  which  corresponds  to  the  side  towards  which  the 
face  is  turned,  upwards  between  the  body  of  the  foetus  and  the 
symphysis  until  the  elbow  is  reached.  Then,  sweep  the  arm 
across  the  face  of  the  child,  at  the  same  time  flexing  the  forearm 
at  the  elbow  as  has  been  described. 

Two  manoeuvres  have  been  described  by  Barnes  *  which  will 
facilitate  the  bringing  down  of  the  arms.  The  first  is  performed 
with  the  object  of  gaining  room  In  bringing  down  the  posterior 
or  sacral  arm  '  carry  the  child's  body  well  forward,  bending  it 
over  the  symphysis  pubis.  The  effect  of  this  is  a  twofold 
advantage.  Space  is  gained  between  the  child's  body  and  the 
sacrum  for  manipulation  ;  and  as  the  child's  body  revolves  round 
the  pubic  centre,  the  further  or  sacral  arm  is  necessarily  drawn 
lower  down  and  commonly  within  reach.  When  the  sacral  arm 
is  freed,  you  reverse  the  manoeuvre,  and  carry  the  child's  trunk 
backwards  over  the  coccyx  as  a  centre.  This  brings  down  the 
pubic  arm.'  The  second  manoeuvre  is  of  use  in  cases  in  which 
either  arm  has  been  carried  slightly  behind  the  head.  '  You 
grasp  the  child's  trunk  in  the  two  hands  above  the  hips,  and 
give  the  body  a  movement  of  rotation  on  its  long  axis,  so  as 
to  bring  its  back  a  little  to  the  left '  (the  patient's  left).  '  The 
effect  of  this  is  to  throw  the  pubic  arm,  which  is  pre'vented  by 
friction  from  following  the  trunk  in  its  rotation,  across  the 
breast.  Then,  your  object  being  accomplished  so  far,  you  call 
to  your  aid  the  first  manoeuvre,  and  bring  the  arm  completely 
down.  This  done,  you  reverse  the  action  and  rotate  the  trunk  in 
the  opposite  direction.  The  sacral  arm  is  thus  brought  to  the 
front  of  the  chest,  and,  by  carrying  the  trunk  back,  your  fingers 
will  easily  complete  the  process.'  The  direction  here  given  so 
to  rotate  the  body  as  to  bring  the  back  a  little  to  the  '  left,'  is 
only  applicable  to  the  position  in  which  the  child  lies  with  its 
back  anterior.  To  make  the  description  more  general,  the  direc- 
tion should  be,  first,  to  rotate  the  anterior  shoulder  towards  the 
back  of  the  child,  and,  then,  the  posterior  shoulder  in  the  opposite 

*  '  Obstetric  Operations,'  third  edition,  p.  208. 


THE  DELIVERY  OF  THE  AFTER-COMING  HEAD  1029 


Fig.  436. — The  Extraction  of  the  After-coming  Head.     The 
Modified  Prague  Method. 


1030  OBSTETRICAL  OPERATIONS 

direction.  The  extent  to  which  the  rotation  is  carried  need  never, 
according  to  Barnes,  exceed  one-eighth  of  a  circle. 

In  some  cases,  the  arm  becomes  so  displaced  behind  the  back 
of  the  head  that  it  actually  lies  below  the  occiput — the  so-called 
nuchal  position  or  dorsal  displacement  of  the  arm  (v.  Fig.  435). 
It  is  doubtful  if  in  such  cases  rotation  of  the  body  would  ever 
bring  the  arm  forwards,  as  the  forearm  would  be  carried  round 
by  the  pressure  of  the  occiput  as  the  foetus  is  rotated.  In  such 
cases,  Herman*  recommends  to  pass  the  hand  along  the  back 
of  the  child,  seize  the  elbow  and  draw  it  downwards  and  for- 
wards. It  is,  however,  probable  that,  if  the  life  of  the  child  is 
to  be  saved,  the  arm  must  be  fractured  in  order  to  get  it  down 
sufficiently  quickly. 

The  Delivery  of  the  After-coming  Head. — In  all  cases  in  which 
the  head  is  not  expelled  by  the  same  or  the  next  contraction 
to  that  by  which  the  shoulders  are  expelled,  assistance  will 
be  required,  or  the  foetus  will  run  the  risk  of  asphyxiation. 
Consequently,  in  many  cases  of  pelvic  presentation  in  which 
the  mechanism  of  expulsion  has  been  in  every  other  way  normal, 
the  after-coming  head  requires  to  be  delivered  artificially.  The 
number  of  different  methods  of  doing  this  is  so  considerable 
that  Winckel  was  able  to  give  a  list  of  twenty-one  distinct 
methods,  which  have  been  recommended  from  time  to  time  by 
different  obstetricians.  Experience  has,  however,  shown  that  the 
most  reliable  and  satisfactory  of  these  are  the  three  methods 
which  we  shall  now  describe,  and  consequently  the  others  possess 
but  an  academic  interest.  Before  proceeding  to  describe  them, 
we  may  insist  on  one  very  obvious  point.  Any  method  to  be 
satisfactory  must  be  capable  of  being  carried  out  with  rapidity, 
and  must  bring  the  head  through  the  pelvis  in  a  manner  similar 
to  the  normal  mechanism  of  expulsion. 

The  Prague  Method. — In  this  method,  which  was  originally 
described  by  Kiwisch,f  the  operator  grasps  the  feet  of  the  child 
with  his  right  hand,  while  he  hooks  the  fingers  of  his  left  hand 
over  the  shoulders  as  shown  (v.  Fig.  436).  The  foetus  is  then 
drawn  forcibly  downwards,  until  the  base  of  the  occipital  bone 
lies  behind  the  lower  margin  of  the  symphysis.  The  legs  are 
carried  forwards  and  swung  as  far  upwards  over  the  abdomen  as 
possible,  and,  by  combined  traction  on  the  feet  and  shoulders, 
extraction  is  accomplished.  It  is  essential  in  doing  this  to 
maintain  flexion  of  the  head.  The  original  Prague  method 
maintains  flexion  by  pressure  upon  the  occiput  with  a  couple  of 
fingers  of  the  left  hand,  but  a  more  suitable  method  and  one 
which  offers  a  better  chance  of  success  consists  in  so  directing 
the  traction  made  by  the  left  hand  that  the  occiput  will  be  pressed 
against  the  back  of  the  pubes  and  the  head  kept  by  this  pressure 
in  a  position  of  flexion.  With  this  object,  the  Prague  method  may 
be  modified  as  follows  : — Having  grasped  the  child  as  has  been 
*  Op.  cit.,  p.  50.  f  Beitrdge  z.  Geburtskunde,  vol.  i.,  p.  69. 


THE  DELIVERY  OF  THE  AFTER-COMING  HEAD 


103 1 


described,  before  applying  any  traction  downwards  draw  the  body 
directly  forwards  with  the  hand  which  holds  the  shoulders.     By 


Fig.  437. — The  Extraction  of  the  After-coming  Head. 
Martin's  Method. 

this  means,  the  occiput  is  pressed  against  the  back  of  the 
symphysis.  Then,  sweep  the  legs  and  body  forwards  over  the 
abdomen  of  the  mother,  and  in  this  way  the  head  will  be  made 


1032  OBSTETRICAL  OPERATIONS 

to  pivot  round  the  point  of  the  occiput  which  is  pressed  against 
the  pubes,  while  at  the  same  time  it  maintains  its  flexed  attitude. 
Either  form  of  the  Prague  method  is,  however,  only  suitable  in 
cases  in  which  the  head  has  passed  through  the  brim  and  lies  in 
the  pelvic  cavity.  Then,  on  account  of  the  ease  and  rapidity  with 
which  it  can  be  performed,  it  is  a  suitable  method  to  adopt. 

Martin's  Method. — This  method,  which  is  also  known  as  the 
Wigand*-Martinf  method,  is  thus  described  by  Winckel.  The 
first  and  second  fingers  of  the  hand  whose  palm  corresponds  to 
the  face  are  introduced  into  the  mouth,  and  the  lower  jaw  is 
directed  to  the  middle  of  the  pelvis,  after  which  the  child's  body 
is  placed  astride  of  the  arm,  and  then  the  fcetal  head  is  forced 
down  through  the  small  pelvis  by  pressing  upon  the  occipital 
region  (v.  Fig.  437).  The  seizure  of  the  chin  serves  less  for 
traction  than  for  directing  the  passage  of  the  head,  which  latter 
is  accomplished  mainly  by  expression.  While  this  pressure  upon 
the  occiput  in  the  direction  of  the  brow  is  continued,  the  head 
is  rotated  about  its  transverse  axis,  and  at  the  same  time  turned 
somewhat  about  its  sagittal  axis,  so  that  the  chin  descends  nearly 
in  the  median  line,  and  the  parietal  bone,  which  was  directed 
posteriorly,  is  pushed  down  under  the  promontory.  In  carrying 
out  this  method,  the  antero-posterior  diameters  of  the  head  must 
be  guided  into  the  oblique  diameter  of  the  brim,  or  in  the  case 
of  a  flattened  pelvis  into  the  transverse  diameter,  and  then  into 
the  transverse  diameter  of  the  outlet  as  the  floor  of  the  pelvis  is 
reached.  This  is  a  most  suitable  method  for  use  in  all  cases, 
and  especially  in  those  in  which  the  head  is  above  the  brim. 
Champetier  de  Ribes  J  and  Ruge  §  have  succeeded  in  delivering 
a  head  by  this  means  in  which  Smellie's  method  failed,  and 
Winckel  ||  states  that  he  has  brought  the  head  of  a  fully- 
developed  child  through  a  pelvis  with  a  conjugate  of  six  centi- 
metres (2f  inches)  in  from  fifteen  to  seventy-five  seconds,  but 
such  a  procedure  can  only  be  possible  under  very  exceptional 
circumstances. 

Smellie's  Method.- — This,  the  last  method  of  extraction  of  the 
head  which  we  shall  describe,  has  been  attributed  to,  and  called 
after,  many  famous  obstetricians.  At  the  present  time,  it  is  most 
usually  known  as  the  Veit-Smellie  method,  but  inasmuch  as 
SmellielT  described  it  in  the  eighteenth  century  and  Veit  not  until 
1863,  of  the  two  the  former  would  appear  to  have  clearly  the 
better  claim  to  the  credit.  Mauriceau**  had,  however,  described 
it  at  an  earlier  date  even  than  Smellie,  namely  in  1668,  and 
consequently    his    name    should    in    reality   be    affixed    to    the 

*  Berlin  Klin.  Wochenschrift,  1886,  p.  660. 

f  Beitrdge  zur  theor.  und prakt.  Geburts.,  Heft  II.,  p.  118,  Hamburg.     1800. 
X  '  Du  passage  de  la  tete  fcetale,'  etc.,  p.  78,  Experience  IX.,  1879. 
§  Zeitschr.  f.  Geburts.  und  Franenkmnk. ,  v.  E.  Martin,  vol.  i. ,  p.  82,  1876. 
II    Op.  at.,  p.  691. 

IT  '  Midwifery,'    New    Sydenham    Society's    edition,    vol.    i.,    p.    307,    and 
vol.  iii.,  Case  303. 

**  '  Traite  des  mal.  des  femmes  grosses,'  derniere  edition.     Paris,  1668. 


THE  DELIVERY  OF  THE  AFTER-COMING  HEAD  1033 

method.  The  names  of  Smellie  and  Veit  have  now  become  so 
intimately  associated  with  the  method  that  to  call  it  by  any 
other   name   save   their   name   would    lead    to   confusion.      The 


Fig.  438. — The  Extraction  of  the  After-coming  Head. 
Smellie's  Method. 

manner  in  which  the  foetus  is  seized  is,  as  it  were,  a  com- 
bination of  the  Prague  and  Martin's  method.  The  hand  corre- 
sponding to  the  side  towards  which  the  face  is  turned  is  passed 


1034  OBSTETRICAL  OPERATIONS 

into  the  vagina,  and  two  fingers  introduced  into  the  mouth. 
The  latter  are  passed  as  far  back  as  possible  in  order  to  avoid 
fracture  of  the  jaw  during  traction  and  to  obtain  a  firm  hold. 
The  body  of  the  child  is  then  placed  astride  of  the  arm.  The 
position  of  this  hand  very  much  resembles  that  of  the  vaginal 
hand  in  Martin's  method,  but  here  it  is  used  both  for  obtaining 
flexion  and  for  traction.  The  fingers  of  the  other  hand  are  then 
passed  over  the  shoulders  of  the  child  at  each  side  of  the  neck  as 
in  the  Prague  method,  but  are  used  solely  for  traction  (v.  Fig.  438). 
The  head  is  guided  by  the  fingers  in  the  mouth  until  its  antero- 
posterior diameters  correspond  to  the  oblique  diameter  of  the 
pelvis,  or  to  the  transverse  diameter  in  the  case  of  a  flattened 
pelvis,  and  is  pulled  down  into  a  position  of  flexion.  Traction  is 
next  made  with  both  hands,  at  first  downwards  and  backwards  to 
bring  the  head  through  the  brim,  then  downwards,  and  finally,  as 
the  outlet  is  reached,  the  body  is  carried  well  forwards  over  the 
abdomen  of  the  mother  and  the  face  rolled  out  from  above  the 
perinaeum.  As  the  head  descends,  its  antero-posterior  diameters 
must  be  guided  from  the  oblique  diameter  into  the  antero-posterior 
of  the  outlet,  as  in  Martin's  method.  If  extra  force  is  required, 
it  can  be  obtained  by  getting  an  assistant  to  press  upon  the  head 
of  the  foetus  through  the  abdominal  wall,  as  in  Martin's  method, 
and,  in  this  way,  a  method  even  more  powerful  than  Martin's 
will  be  obtained. 

A  few  words  must  be  said  regarding  the  application  of  the 
forceps  to  the  after-coming  head,  though  it  does  not  appear  to  us 
that  there  is  a  large  field  for  its  use.  In  the  case  of  a  living  child, 
Martin's  or  Smellie's  method  of  extraction  is  more  suitable  and 
affords  a  better  prospect  of  life  to  the  child,  since  each  of  them 
can  be  adopted  more  rapidly,  and  at  least  as  much  force  can 
be  applied  as  by  the  forceps.  Further,  as  the  head  can  be  better 
guided  by  the  fingers  into  correspondence  with  the  diameters  of 
the  pelvis  than  it  can  with  the  forceps,  the  effective  part  of  the 
force  applied  is  also  greater  in  manual  than  in  forceps  extraction. 
If,  on  the  other  hand,  the  foetus  is  dead,  and  extraction  by  Martin 
or  Smellie's  method  has  failed,  it  is  preferable  to  perforate  the 
head  and  then  extract  it,  than,  by  applying  the  forceps,  to  subject 
the  mother  to  the  crushing  of  the  soft  parts  which  must  result 
during  the  delivery  of  the  head. 

As  we  have  mentioned,  in  certain  cases  the  head  may  rotate 
so  that  the  face  is  directed  forwards.  In  such  cases,  one  of  two 
methods  of  delivery  may  be  adopted.  If  the  face  is  lying  behind 
the  pubes,  the  body  of  the  foetus  is  carried  as  far  backwards  as 
possible,  and  the  fingers  are  slipped  into  the  vagina  between 
the  chin  and  the  pubes  until  the  mouth  is  reached.  Then,  by  trac- 
tion upon  the  jaw,  as  in  Smellie's  method,  the  face  is  pulled  down 
from  behind  the  symphysis,  the  body  at  the  same  time  being  still 
further  depressed.  In  this  manner,  the  face,  the  sinciput,  and  the 
vertex   are  in  turn   born,   the  occiput  following  last.     If,  how- 


THE  DELIVERY  OF  THE  AFTER-COMING  HEAD 


io35 


ever,  the  chin  has  become  caught  above  the  pubis,  the  delivery  of 
the  head  is  more  difficult.  In  such  cases,  it  may  sometimes  be 
possible  to  rotate  the  head  in  the  manner  suggested  by  Madame 
La  Chapelle,  by  passing  the  hand  upwards  in  the  hollow  of  the 
sacrum  until  it  lies  over  the  occiput,  and  then  carrying  it  round 
anteriorly  in  such  a  manner  as  to  bring  the  occiput  to  the  side. 
The  head  can  be  then  delivered  by  any  of  the  ordinary  methods. 


Fig.  439 — The  Extraction  of  the  After  coming  Head  in  which  the 
Face  has  Rotated  Anteriorly  and  the  Chin  has  caught  above 
the  Symphysis. 


If  this  cannot  be  done,  it  may  be  possible  to  deliver  the  head  by 
a  process  the  reverse  of  the  one  we  have  described  for  use  in  cases 
where  the  face  is  behind  the  symphysis.  The  body  of  the  child 
is  carried  as  far  forwards  over  the  abdomen  of  the  mother  as 
possible  and  the  occiput  thus  made  to  roll  out  from  above  the 
perinseum,  the  vertex,  sinciput,  and  face  successively  following 
(v.  Fig.  439).  If  this  procedure  fails,  the  child  by  this  time  will 
be  dead  and  perforation  should  be  performed. 


CHAPTER  IV 

CONSERVATIVE    AND    RADICAL    CESAREAN    SECTION. 
SYMPHYSIOTOMY 

Conservative  and  Radical  Cassarean  Section — History  of  the  Operation  — 
Conservative  Caesarean  Section — Radical  Cassarean  Section,  The  Porro- 
Caesarean  Operation,  Partial  Hysterectomy,  Complete  Hysterectomy. 
Symphysiotomy — History  of  Operation — Effect  of  Operation  on  the 
Pelvis — Indications  —  Instruments — Assistants — Operation  —  After-treat- 
ment— Prognosis. 


CONSERVATIVE  AND  RADICAL  CESAREAN 
SECTION 

Under  the  terms  '  conservative  Caesarean  section  '  and  '  radical 
Caesarean  section,'  we  propose  to  include  all  operations  in  which 
the  foetus  is  delivered  through  incisions  in  the  abdominal  wall  and 
the  uterus.  In  conservative  Caesarean  section,  the  incision  in  the 
uterus  is  sutured  after  the  removal  of  the  ovum,  and  the  uterus 
is  allowed  to  remain.  In  radical  Cassarean  section,  the  removal 
of  the  foetus  is  followed  by  the  removal  of  the  uterus,  either 
partially  or  completely.  We  thus  use  the  term  '  conservative 
Caesarean  section '  as  the  equivalent  of  the  term  Caesarean 
section — as  usually  used,  and  the  term  '  radical  Caesarean 
section '  to  designate  the  type  of  operation  which  is  generally 
termed  Porro's  operation.  The  objection  to  adhering  to  the 
older  terms  is  that  Porro's  operation,  as  devised  by  Porro,  has 
to  all  intents  and  purposes  passed  out  of  modern  obstetrical 
surgery,  and  that  the  limitation  of  the  term  Caesarean  section  to 
cases  in  which  the  uterus  is  left  behind  is  scarcely  justified  by 
its  meaning. 

The  origin  of  the  term  Caesarean  section  has  given  rise  from 
time  to  time  to  a  considerable  amount  of  discussion,  and  many 
and  widely  different  explanations  of  it  have  been  brought  forward. 
The  most  probable  explanation  is  that  the  word  Caesarean  is 
derived  from  casus,  and  was  selected  because  the  individual 
so  delivered  was  casus  e  matris  utero.  Another  possible  explana- 
tion is  that  Numa  Pompilius,  in  his  code  of  laws,  included  one 
making  it   obligatory  to  remove  the  foetus  before  burial  in  the 

1036 


THE  ORIGIN  OF  CESAREAN  SECTION  1037 

case  of  all  women  who  died  in  the  last  few  weeks  of  pregnancy, 
and  that  this  law  was  known  as  the  Lex  Regia.  Under  the 
emperors,  it  is  said  that  the  latter  term  was  converted  into  Lex 
Caesarea.  If  this  was  so,  it  offers  a  very  reasonable  explanation 
of  the  origin  of  the  term.* 

The  first  performance  of  Caesarean  section  on  the  living  woman 
is  believed  to  have  been  carried  out  by  a  swine-gelder  named 
Jacques  Nufer,  of  Siegerhausen,  in  the  year  1500  a.d.  ;  and  a 
very  complete  account  of  this  and  of  the  other  earlier  operations 
is  to  be  found  in  a  work  I  in  defence  of  that  operation  written 
by  John  Hull,  M.D.,  of  Manchester,  in  1858.  Hall  was  able  to 
collect  the  results  of  137  operations,  performed  between  the  years 
1500  and  1786,  in  no  of  which  the  mother  recovered  and  in  27  of 
which  she  died.  Hull's  statistics  were,  however,  collected  with 
the  object  of  proving  the  permissibility  of  the  operation,  and  it 
is  probable  that  he  did  not  give  the  same  prominence  to  unsuc- 
cessful as  to  successful  cases,  for,  in  1867,  Meyer  \  collected  the 
statistics  of  1,605  cases,  with  a  total  mortality  of  54  per  cent. 
This  terrible  mortality  was  doubtless  due  to  the  non-suture  of 
the  uterine  wound,  and  to  haemorrhage  and  sepsis.  In  1876, 
the  first  step  in  the  improvement  of  Cesarean  section  was  made 
when  Porro§  introduced  the  operation  to  which  his  name  has 
been  attached.  In  this  operation,  after  the  removal  of  the  foetus, 
the  uterus  was  amputated  above  the  vaginal  insertion,  and  the 
stump  sutured  into  the  lower  angle  of  the  abdominal  wound. 
Thus,  haemorrhage  was  prevented  and  the  risk  of  sepsis  was 
lessened. 

The  next  great  advance,  and  that  which  is  responsible  for 
placing  Caesarean  section  on  its'  present  firm  basis,  was  the 
introduction  by  Sanger,;]  in  1882,  of  the  practice  of  suturing 
the  uterine  incision  ;  indeed,  so  far  as  the  operation  of  con- 
servative Caesarean  section  is  concerned,  few  modifications  of 
importance  have  been  introduced  since  that  date.  The  opera- 
tion introduced  by  Porro  has,  however,  been  very  considerably 
improved,  and  the  technique  of  radical  Caesarean  section,  in 
which  the  greater  part  of  the,  or  the  entire,  uterus  is  removed, 
has  improved  pari  passu  with  the  improvements  in  the  opera- 
tion of  hysterectomy  for  myomata.  Porro's  operation  possessed 
the  great  disadvantages  that  the  risk  of  sepsis  from  the  exposure 

*  Whatever  may  be  the  true  origin  of  the  term,  we  may  say,  with  the  object 
of  removing  a  popular  misconception,  that  there  is  no  evidence  to  show  that 
it  arose  in  a  supposed  delivery  of  Julius  Caesar  by  Caesarean  section,  or  in  the 
initial  performance  of  the  operation  by  an  individual  of  the  name  of  Caesar. 

f  '  A  Defence  of  the  Caesarean  Operation,  with  Observations  on  Embryulcia 
and  the  Section  of  the  Symphysis  Pubis,  addressed  to  Mr.  W.  Simmons,  of 
Manchester,  author  of  "Reflections  on  the  Propriety  of  Performing  the 
Caesarean  Operation,"  '  by  John  Hull,  M.D.,  Manchester,  1858. 

%  '  Sulla  gastroisterotomia.'     Napoli,  1867. 

§  '  Delia  amputazione  utero  ovarica,'  etc.     Milan,  1876. 

||    '  Der  Kaiserschnitt  bei  Uterusmyomen,'  etc.     Leipzig,  1882. 


1038  OBSTETRICAL  OPERATIONS 

and  sloughing  of  the  uterine  stump  was  considerable ;  that  the 
presence  of  the  stump  in  the  lower  angle  of  the  wound  paved 
the  way  for  the  subsequent  occurrence  of  ventral  hernia ;  and 
that  convalescence  was  protracted.  In  the  modern  operation  of 
radical  Cesarean  section,  the  uterus  is  either  amputated  above 
the  vagina,  and  the  stump  ligatured  and  covered  by  peritoneum, 
or  the  entire  uterus  is  removed. 

Indications. — The  principal  indication  for  Caesarean  section  is 
obstruction  to  the  passage  of  the  foetus  through  the  pelvis.  Such 
an  obstruction  may  be  due  to  pelvic  contraction  ;  to  the  presence 
of  solid  irreducible  tumours ;  or  to  extreme  cicatrisation  of  the 
vaginal  tissues.  If  the  obstruction  is  such  that  the  passage  of 
even  a  mutilated  foetus  is  impossible,  and  that  symphysiotomy 
will  not  give  a  sufficient  degree  of  enlargement  to  allow  a  living 
foetus  to  be  extracted,  Cesarean  section  is  said  to  be  absolutely 
indicated.  If,  on  the  other  hand,  it  is  possible  to  effect  the 
delivery  of  the  foetus  by  other  means,  such  as  perforation  or 
symphysiotomy,  there  is  said  to  be  a  relative  indication  for 
Caesarean  section.  The  different  indications  may,  accordingly, 
be  grouped  as  follows  : — 

Absolute  Indications. — (1)  Absolute  pelvic  contraction,  i.e., 
a  true  conjugate  of  less  than  i\  inches  in  the  case  of  a  flattened 
pelvis,  or  of  less  than  o.\  inches  in  a  generally  contracted  pelvis. 

(2)  Solid  irremovable  tumours  blocking  the  pelvis,  as  in  the 
case  of  bony  tumours  springing  from  the  pelvic  walls,  carcinoma 
of  the  cervix  or  vagina,  uterine  myomata  springing  from  the 
lower  uterine  segment,  and  ovarian  tumours  impacted  in  Douglas' 
pouch. 

(3)  Extreme  cicatrisation  of  the  vaginal  tissues  sufficient  to 
prevent  the  vagina  from  being  dilated  without  the  rupture  of 
adjacent  organs. 

Relative  Indications. — (1)  Slighter  degrees  of  pelvic  contrac- 
tion, i.e.,  pelves  which  measure  from  2^  to  3^  inches  in  the  true 
conjugate  in  the  case  of  flattened  pelvis,  from  i\  to  3^  inches 
in  the  case  of  generally  contracted  pelvis,  provided  that  the 
foetus  is  alive. 

(2)  Narrowing  of  the  genital  passages  by  tumours  or  cicatrisa- 
tion where  it  is  possible  to  extract  a  mutilated  foetus,  but  in 
which  the  foetus  is  alive. 

In  the  presence  of  absolute  indications,  Caesarean  section  must 
be  performed  whether  the  foetus  is  alive  or  dead,  and  whatever 
the  circumstance  under  which  the  case  is  met.  In  the  presence 
of  relative  indications,  the  operation  is  only  indicated  if  the  foetus 
is  alive,  and  its  performance  must  be  further  governed  by  the 
circumstances  under  which  the  operation  has  to  be  performed. 
In  consequence  of  the    marked  improvement  which  has  taken 


THE  INDICATIONS  FOR  CESAREAN  SECTION  1039 

place  in  the  maternal  prognosis  after  Cesarean  section,  when 
performed  by  a  skilled  operator  under  favourable  circumstances, 
Whitridge  Williams  advocates  the  extension  of  the  limits  for  the 
performance  of  the  operation  in  cases  of  contracted  pelvis.  He 
suggests*  that  the  operation  should  be  considered  to  be  abso- 
lutely indicated  in  cases  in  which  the  true  conjugate  is  less  than 
2§  inches  in  flattened  pelvis,  or  than  3  inches  in  generally  con- 
tracted pelvis,  and  to  be  relatively  indicated  in  cases  in  which  it 
is  less  than  3-|  inches  in  flattened  pelvis,  or  than  3!  inches  in 
generally  contracted  pelvis.  He  very  properly  adds,  however, 
that  the  limits  should  only  be  thus  extended  in  the  case  of  patients 
in  good  condition,  and  in  whom  the  operation  can  be  undertaken 
under  favourable  circumstances. 

In  addition  to  the  foregoing  indications,  Caesarean  section 
has  been  recommended  in  certain  cases  of  eclampsia  and  of 
concealed  accidental  haemorrhage,  and  numerous  cases  in  which 
the  operation  has  been  successfully  performed  in  the  presence  of 
these  complications  are  to  be  found  in  medical  literature.  It  is 
probable  that  the  introduction  of  Bossi's  dilator  has  considerably 
lessened  the  small  number  of  cases  in  which  Caesarean  section 
may  be  indicated  in  eclampsia  ;  and  it  is  possible  that  similar 
means  of  effecting  delivery  may  also  prove  of  value  in  those  cases 
of  concealed  accidental  haemorrhage  for  which  in  the  past  there 
did  not  appear  to  be  any  treatment  possible  other  than  radical 
Caesarean  section. 

Having  considered  the  cases  in  which  Caesarean  section  is 
indicated,  it  remains  to  consider  the  circumstances  which  lead  to 
the  adoption  of  the  conservative  or  the  radical  operation.  It  may 
be  laid  down  as  a  broad  principle,  based  on  the  excellent  results 
obtained,  that  the  conservative  operation  is  the  operation  of 
choice  in  all  cases  in  which  the  presence  of  some  complication 
does  not  call  for  the  removal  of  the  uterus.  In  other  words,  the 
removal  of  a  healthy  uterus  is  no  longer  required  in  order  to 
lessen  the  risk  of  operation.  On  the  other  hand,  in  certain 
pathological  conditions,  the  removal  of  the  uterus  is  called  for 
after  the  extraction  of  the  foetus.  The  most  important  of  these 
conditions  are  as  follows  :  — 

(1)  Defective  development  of  the  uterus. 

(2)  The  presence  of  uterine  fibro  -  myomata  or  malignant 
disease,  which  would  call  for  hysterectomy  even  if  the  patient 
was  not  pregnant. 

(3)  The  presence  of  incurable  and  extreme  cicatrisation  of  the 
vagina. 

(4)  If  there  is  reason  to  believe  that  septic  infection  of  the 
uterus  has  occurred. 

(5)  If  severe  ante-partum  haemorrhage  has  occurred,  and  there 
is  reason  to  anticipate  the  occurrence  of   further  haemorrhage. 

*  '  Obstetrics,'  p.  402. 


1040  OBSTETRICAL  OPERATIONS 

Cases  in  which  the  operation  is  performed  on  account  of  con- 
cealed accidental  haemorrhage  fall  under  this  head. 

(6)  Osteo-malacia,  with  the  object  of  improving  the  prognosis 
of  the  disease. 

In  all  cases,  partial  hysterectomy  is  the  more  rapid  and  easier 
procedure,  but,  in  cases  of  malignant  disease  of  the  cervix  or 
of  septic  infection  of  the  uterus,  total  hysterectomy  should  be 
performed. 

Preparation  of  the  Patient. — If  the  operation  is  deliberately 
undertaken,  the  patient  must  be  prepared  as  for  an  ordinary 
abdominal  cceliotomy.  Thirty-six  hours  before  the  operation  she 
is  given  a  brisk  purgative,  which  is  followed  by  an  enema  a  few 
hours  before  the  operation.  On  the  evening  before  the  operation, 
the  patient  is  given  a  warm  bath,  the  pubes  is  shaved,  the  skin  of 
the  abdomen  is  washed  with  soap  and  water  and  finally  with  ether, 
and  a  compress  soaked  in  a  one  per  cent,  solution  of  corrosive 
sublimate  in  glycerine  is  applied  over  the  proposed  site  of  incision. 
This  compress  remains  in  situ  until  the  patient  is  on  the  operating 
table,  when  it  is  removed  and  the  skin  again  washed  with  soap 
and  water,  then  with  ether,  and  finally  with  corrosive  sublimate 
solution,  i  in  500.  If,  however,  as  usually  happens,  the  operation 
is  undertaken  in  an  emergency,  the  preliminary  preparations 
must  necessarily  be  dispensed  with,  and  increased  care  must  be 
taken  with  the  washing  and  disinfection  of  the  skin  at  the  time 
of  the  operation.  The  vagina  should  be  well  douched,  and 
washed  out  with  lysol  solution  shortly  before  the  operation,  and, 
if  a  complete  hysterectomy  is  to  be  performed,  it  is  well,  if  it  is 
possible  to  do  so,  to  insert  a  tampon  of  iodoform  gauze,  after 
a  preliminary  douching,  twelve  hours  before  the  operation. 
Finally,  just  before  the  patient  is  placed  on  the  table,  the  catheter 
should  be  passed,  unless  it  is  certain  that  the  patient  has  emptied 
the  bladder  spontaneously. 

Time  at  which  to  Operate. — It  is  usually  taught  and  practised 
that  the  best  time  to  perform  Caesarean  section  is  after  the  patient 
has  come  into  labour,  and  prior  to  the  rupture  of  the  membranes. 
The  presence  of  labour  pains  ensures  that  normal  contraction 
and  retraction  will  occur  after  delivery,  and  the  fact  that  labour 
has  been  in  progress  for  some  little  time  ensures  that  the  uterine 
orifice  will  be  sufficiently  dilated  to  allow  the  escape  of  the 
lochia.  The  advantages  of  operating  while  the  membranes  are 
intact  are,  first,  that  the  uterine  wall  is  slightly  thinner,  and  that 
consequently  so  many  vessels  are  not  divided  by  the  incision, 
and,  secondly,  that  it  is  easier  to  deliver  the  foetus  when  it  floats 
freely  in  the  uterus  than  when  it  is  gripped  by  the  uterine  wall. 
There  is,  however,  a  grave  objection  to  being  guided  solely  by 
these  two  conditions  as  they  frequently  necessitate  the  per- 
formance of  the  operation  at  night,  by  artificial  light.  In  con- 
sequence of  this,  Kelly*  was  led  to  neglect  the  older  principles 
*  '  Operative  Gynaecology,'  vol.  ii. ,  p.  417. 


CONSERVATIVE  CMS  ARE  AN  SECTION  104 1 

and  to  operate  at  the  end  of  pregnancy  without  waiting  for  the 
onset  of  uterine  contractions.  His  results  by  so  doing  were 
excellent,  and  he,  consequently,  recommends  that,  whenever  the 
end  of  pregnancy  can  be  accurately  fixed  by  reference  to  the 
date  of  the  cessation  of  menstruation  or  by  the  measurement 
of  the  fcetus,  the  operator  should  fix  the  day  and  hour  for  the 
operation,  as  in  the  case  of  any  other  operation.  In  such  cases, 
however,  some  steps  must  be  taken  to  dilate  the  cervical  canal 
in  order  to  provide  for  the  free  escape  of  the  lochia  during  the 
puerperium.  If  it  can  be  shown  that  proper  contraction  occurs 
after  the  emptying  of  the  uterus  in  cases  in  which  the  patient  was 
not  in  labour,  there  can  be  no  doubt  that  the  course  recommended 
by  Kelly  is  correct.  His  cases  all  show  that  due  contraction 
does  occur,  as  is  to  be  expected  in  view  of  the  fact  that  contrac- 
tions occur  after  the  emptying  of  the  uterus  per  vaginam  in  cases 
of  accouchement  force . 

Instruments. — The  following  instruments  are  required  : — Two 
scalpels ;  a  dozen  clip  forceps ;  three  pairs  of  scissors,  one 
sharp-pointed,  one  blunt-pointed,  and  one  curved  on  the  flat,  all 
tolerably  stout  and  with  handles  of  medium  length  ;  retractors  ; 
four  or  five  long,  straight  and  curved,  narrow-bladed  clamp 
forceps ;  six  stouter  clamp  forceps  with  blades  of  different 
lengths ;  rubber  gloves  for  operators  and  assistants  ;  a  couple 
of  sponge-holders ;  two  toothed  fistula  forceps ;  three  or  four 
dozen  sponges  of  gauze ;  needles  and  holders  ;  suture  materials ; 
two  short,  and  two  long,  dissecting  forceps  with  sharp  teeth. 

Assistants.  —  In  addition  to  the  operator,  four  assistants  are 
required  it  they  can  be  obtained.  The  chief  assistant  stands 
opposite  and  helps  the  operator.  A  second  assistant  attends  to  the 
ligatures  and  instruments.  A  third  gives  all  necessary  general  help 
and  attends  to  the  infant  after  its  removal.  A  fourth  administers 
the  anaesthetic. 

Operations. — Four  different  operations  must  be  described,  three 
of  which  fall  under  the  head  of  radical  Csesarean  section.  These 
are  : — 

(1)  Conservative  Cesarean  Section — the  '  Sanger-Csesarean  ' 
operation. 

(2)  Radical  Csesarean  Section. 

(a)  The  classical  '  Porro-Csesarean  '  operation. 

(b)  Partial  hysterectomy. 

(c)  Complete  hysterectomy. 

Conservative  Cesarean  Section.  —  The  operation  of  con- 
servative Caesarean  section  consists  in  the  opening  of  the  ab- 
dominal cavity  in  the  middle  line,  the  incision  of  the  wall  of  the 
uterus,  the  removal  of  the  foetus,  and  the  suture  of  the  uterine 
and  abdominal  incision.  The  steps  of  the  operation,  as  usually 
performed,  are  as  follows  :  — 

(1)  The  abdomen  is  opened  in  the  middle  line  by  a  longitudinal 

66 


1042  OBSTETRICAL  OPERATIONS 

incision  about  eight  inches  in  length.     One-third  of  the  incision 
lies  above  the  umbilicus,  the  remainder  below. 

(2)  The  uterus  is  opened  in  the  middle  line  by  a  longitudinal 
incision  about  six  inches  in  length. 

(3)  The  fcetus  is  rapidly  extracted,  and  the  cord  is  clamped  and 
divided. 

(4)  The  uterus  is  lifted  out  of  the  abdomen,  and  an  assistant 
grasps  the  lower  segment  as  far  down  as  possible,  and  holds  it 
tightly  to  prevent  the  occurrence  of  haemorrhage. 

(5)  The  placenta,  membranes,  and  blood-clot,  are  removed 
from  the  uterus,  and  the  cervix  is  ascertained  to  be  patulous, 
or  else  it  is  dilated  by  pushing  the  fingers  downwards  through  it. 

(6)  The  uterine  incision  is  sutured. 

(7)  The  peritoneal  cavity  is  cleansed  from  any  blood,  etc.,  that 
may  have  escaped  into  it,  the  uterus  is  replaced,  and  the  omentum 
drawn  into  the  most  suitable  position. 

(8)  The  abdominal  incision  is  sutured. 

The  operation  is  carried  out  as  follows :— The  patient  is  placed 
on  an  operating  table,  or  if  the  operation  is  performed  in  a  private 
house  on  a  long  and  rigid  table  which  is  completely  covered  by 
sterilised  sheets.  After  the  preparation  of  the  field  of  operation, 
the  abdomen  .is  opened  in  the  usual  manner  in  the  middle  line, 
by  an  incision  eight  inches  in  length.  One-third  of  this  incision 
lies  above  the  umbilicus,  and  the  remaining  two-thirds  below  it. 
As  soon  as  the  peritoneum  has  been  divided,  the  anterior  surface 
of  the  uterus  appears  in  the  wound.  As  a  rule,  the  uterine  wall 
is  incised  while  the  uterus  is  still  in  the  abdominal  cavity,  as 
its  removal  prior  to  emptying  necessitates  a  longer  abdominal 
incision.  If,  however,  there  is  any  reason  to  believe  that  intra- 
uterine decomposition  has  occurred,  it  is  better  to  enlarge  the 
incision  and  draw  the  uterus  out  before  opening  it,  as  thus 
the  risk  of  peritoneal  infection  is  lessened.  If  the  uterus  is 
incised  in  situ,  care  must  be  taken  that  it  lies  mesially  in  the 
abdomen  and  that  there  is  no  lateral  rotation.  This  can  be 
determined  by  noting  the  position  of  the  tubal  insertions,  and,  if 
there  is  any  rotation,  it  must  be  corrected.  An  assistant  holds 
the  uterus  in  this  position  and  at  the  same  time  keeps  the 
abdominal  wall  firmly  pressed  against  its  sides,  in  order  to 
prevent,  so  far  as  possible,  the  escape  of  liquor  amnii  into  the 
peritoneal  cavity.  If  the  uterus  is  drawn  out  through  the  wound, 
it  is  padded  round  with  gauze  sponges  with  the  same  object. 

Individual  operators  differ  with  regard  to  the  best  manner  of 
making  the  uterine  incision.  It  is  usually  recommended  to  make 
an  incision  of  the  full  length  at  a  single  stroke,  going  down  as 
close  as  possible  to  the  chorion  without  cutting  it.  Kelly,  on 
the  other  hand,  recommends  to  make  first  a  small  incision,  and 
divide  the  wall  carefully  and  slowly  down  to  the  membranes. 
Then,  to  puncture  the  membranes,  and,  as  the  fluid  is  escaping, 
to  introduce  two  fingers,  and,  lifting  up  the  edge  of  the  wall,  to 


CONSERVATIVE  CESAREAN  SECTION  1043 

extend  the  incision  as  necessary.  This  is  perhaps  the  better 
method.  The  most  convenient  site  for  the  incision  is  in  the 
middle  line,  but,  if  it  is  obvious  that  by  making  the  incision 
there  the  placenta  will  be  wounded,  it  is  better  to  keep  a  little 
to  one  side,  in  order,  even  if  we  cannot  get  quite  clear  of  the 
placenta,  at  all  events  to  keep  as  near  to  the  edge  as  possible. 

The  presence  of  the  placenta  in  the  line  of  the  incision  is 
always  a  source  of  additional  trouble,  as  it  increases  the  amount  of 
maternal  blood  lost,  and,  if  incision  of  the  placenta  is  practised, 
the  amount  of  fcetal  blood  also.  There  does  not,  however,  appear 
to  be  any  certain  method  of  exactly  determining  the  position  of 
the  placenta  relative  to  the  proposed  site  of  incision.  In  some 
cases,  the  increased  difficulty  in  palpating  the  fcetal  parts  through 
the  anterior  uterine  wall,  and  the  apparent  increased  thickness 
and  vascularity  of  the  uterine  wall,  may  suggest  its  presence. 
Murdoch  Cameron,*  who  has  a  large  experience  of  Cesarean 
sections,  states  that  the  foetus  always  lies  in  the  uterus  in  such 
a  manner  that  its  limbs  correspond  to  the  placental  site.  If  the 
back  of  the  foetus  is  directed  posteriorly,  he  considers  that  the 
placenta  is  usually  attached  to  the  anterior  uterine  wall,  and,  if 
the  back  is  directed  anteriorly,  to  the  posterior  uterine  wall. 
The  recognition  of  the  site  of  the  placenta  is  not,  however, 
of  very  great  practical  value,  as,  even  if  the  placenta  is  known 
to  be  directly  in  the  line  of  incision,  it  is  usually  impossible 
to  avoid  it.  Cameron  recommends  that  in  all  cases,  with  the 
object  of  lessening  the  amount  of  blood  lost,  an  oval  vulcanite 
pessary  should  be  pressed  firmly  against  the  uterine  wall, 
so  that  a  portion  of  the  site  of  the  incision  falls  within  it, 
and  this  part  of  the  wall  then  incised.  This  is  a  very  easily 
adopted  precaution,  but  it  adds  an  unnecessary  complica- 
tion to  the  operation,  and  as  the  pessary  must  be  removed  in 
order  to  extend  the  incision,  the  amount  of  blood  that  is  saved 
cannot  be  very  great.  If  the  placenta  lies  beneath  the  incision, 
the  fingers  should  be  quickly  pushed  between  it  and  the  uterine 
wall  at  whatever  point  is  believed  to  be  nearest  to  the  placental 
edge,  and  the  placenta  rapidly  detached  until  the  edge  is  reached, 
when  the  membranes  can  be  incised.  If  this  cannot  be  done,  the 
placental  substance  must  be  rapidly  incised,  or  pierced  with  the 
hand,  as  in  oentral  placenta  pra?via  (Cameron).  In  such  cases, 
in  order  to  avoid  loss  of  fcetal  blood,  the  cord  should,  if  possible, 
be  rapidly  hooked  out  and  compressed  by  the  assistant  while  the 
foetus  is  being  extracted. 

An  innovation  in  the  site  of  the  uterine  incision  was  suggested 
and  practised  by  Fritz  in  1897,!  to  the  effect  that  the  incision 
should  be  made  transversely  through  the  fundus,  instead  of 
longitudinally  through  the  anterior  wall.     The  advantage,  which 

*  '  Text-book  of  Gynaecology,'  edited  by  C.  L.  Reed,  M.D. ,  1901,  p.  465. 
f  '  Ein  neuer  Schnitt   bei   der    Sectio   Cassarea,'  Centralbl.   f.   Gyn.,   1897, 
pp.  561-565- 

66—2 


1044  OBSTETRICAL  OPERATIONS 

he  considered  such  an  incision  offered,  was  diminished  haemor- 
rhage, in  that,  as  the  vessels  pursue  a  transverse  course  across 
the  uterus,  fewer  of  them  would  be  divided.  This  mode  of 
incision  has  been  adopted  by  several  operators  with  results 
that  are  very  good,  but  still  no  better  than  those  obtained  in 
cases  in  which  the  more  usual  incision  was  made.  The  fundal 
incision  is  open  to  the  objection  that,  for  its  adoption,  the 
uterus  must  first  be  lifted  out  of  the  abdominal  cavity,  and  that 
this  necessitates  a  longer  abdominal  incision  than  would  be  other- 
wise necessary.  Also,  as  Williams  points  out,  if  the  uterine 
cavity  subsequently  becomes  infected,  there  is  more  risk  of  the 
infection  extending  to  the  peritoneal  cavity  through  a  fundal 
incision  which  is  in  direct  contact  with  the  intestines,  than  there 
is  in  the  case  of  an  anterior  incision  which  can  become  adherent 
to  the  abdominal  wall. 

As  soon  as  the  uterine  incision  has  been  completed,  the  next 
step  is  the  extraction  of  the  foetus.  Two  methods  of  doing  this 
are  respectively  advised  by  different  operators.  One  consists 
in  passing  the  hand  quickly  down  to  the  lower  part  of  the  uterus 
and  scooping  out  the  head,  the  remainder  of  the  foetus  following. 
The  other  consists  in  seizing  the  foetus  by  the  feet,  and  extracting 
it  by  traction  upon  them.  The  advantage  of  the  first  method 
is  that  it  avoids  the  risk  of  the  edges  of  the  uterine  incision  con- 
tracting round  the  neck  of  the  foetus.  If  the  membranes  are 
unruptured,  head  extraction  is  possible,  but,  if  the  membranes 
have  been  long  ruptured,  it  is  difficult,  as  it  practically  neces- 
sitates the  performance  of  internal  version.  In  such  cases,  leg 
extraction  is  necessary,  and,  to  avoid  any  delay  through  the 
catching  of  the  chin  in  the  edges  of  the  wound,  the  head  as  it 
emerges  may  be  kept  in  a  position  of  flexion  by  passing  the 
fingers  into  the  mouth. 

If  the  head  has  become  impacted  in  the  pelvic  brim,  there 
may  be  some  difficulty  in  its  extraction.  In  such  cases,  the 
legs,  which  have  been  drawn  out  through  the  incision,  are  seized 
in  one  hand,  while  the  other  hand,  passed  down  into  the  bottom 
of  the  uterus,  seizes  the  foetus  by  the  neck  and  shoulders. 
At  the  same  time,  with  one  finger  the  head  is  kept  in  a  position 
of  flexion  either  by  traction  on  the  jaw  or  by  pressure  on  the 
occiput,  according  as  the  position  of  the  foetus  mak«6  one  or  other 
manipulation  the  easier.  The  head  is  then  drawn  upwards, 
keeping  it  at  first  in  the  axis  of  the  pelvic  brim.  If  this  course 
is  not  successful  in  freeing  the  head,  an  assistant  should  pass 
his  fingers  into  the  vagina  and  push  up  the  head  as  quickly  as 
possible.  The  essentials  in  the  delivery  of  the  foetus  are  rapidity 
and  gentleness.  If  there  is  any  delay  it  may  cost  the  life  of 
the  infant,  especially  in  cases  in  which  the  placenta  has  been 
wounded,  and,  if  undue  force  is  used,  laceration  of  the  uterus 
may  result.  As  soon  as  the  infant  is  extracted,  the  cord  is 
clamped  and  divided,  and  the  infant  is  handed  over  to  the  care  of 


CONSERVATIVE  CESAREAN  SECTION  1045 

the  assistant  whose  duty  it  is  to  attend  to  it.  The  uterus  is  then 
drawn  out  through  the  abdominal  wound. 

As  a  rule,  as  soon  as  the  fcetus  has  been  extracted,  the  uterus 
contracts  and  checks  all  haemorrhage.  If  contractions  do  not 
immediately  occur,  and  there  is  much  bleeding  either  from  the 
incision  or  the  wounded  placental  site,  the  assistant  firmly  grasps 
the  uterus  round  its  lower  segment  with  both  hands,  and  thus 
compresses  the  vessels.  The  use  of  a  temporary  elastic  ligature 
round  the  lower  segment  of  the  uterus  was  recommended  by 
Litzmann  as  a  prophylactic  measure  against  haemorrhage.  It  is, 
however,  an  unnecessary  precaution,  and  is  also  said  to  interfere 
with  the  subsequent  contraction  of  the  uterus. 

As  soon  as  the  uterus  has  been  drawn  out  of  the  abdomen, 
a  large  and  flat  gauze  sponge,  wrung  out  of  hot  water,  is  placed 
above  and  behind  it,  in  such  a  manner  as  to  prevent  the 
escape  of  the  intestines,  and,  if  necessary,  the  edges  of  the 
abdominal  wound  may  also  be  brought  together  above  the  uterus 
by  an  American  forceps.  If  the  placenta  has  been  detached, 
it  is  drawn  carefully  out  of  the  uterus,  taking  care  to  bring 
all  the  membranes  with  it.  If  it  is  still  adherent,  it  is  separated 
with  the  fingers  in  the  usual  manner.  Care  must  be  taken  that 
large  pieces  of  membrane  are  not  left  behind,  but  it  is  quite 
unnecessary  to  spend  time  in  scraping  away  all  small  fragments 
of  decidua.  If  the  uterus  does  not  contract  properly,  contractions 
may  be  stimulated  by  covering  the  whole  organ  with  sponges 
wrung  out  of  very  hot  water,  and  then  compressing  and  kneading 
it  through  the  sponges.  As  a  rule,  however,  contraction  is 
immediate  and  sufficient  once  the  uterus  is  emptied. 

The  next  step  is  the  suture  of  the  uterine  incision.  The  usual 
suture  material  is  fine  silk.  Catgut  is  objectionable,  as  it  may 
be  absorbed  too  soon.  The  sutures  are  passed  as  interrupted 
sutures,  from  above  downwards.  They  are  entered  about  half  a 
centimetre  from  the  edge  of  the  incision,  and  traverse  the  entire 
thickness  of  the  uterine  wall  with  the  exception  of  the  mucosa. 
They  are  inserted  about  a  centimetre  apart,  and,  after  each  suture 
is  passed,  the  suture  two  behind  it  is  tied.  This  checks  all  bleed- 
ing in  the  neighbourhood  of  the  tied  suture,  and,  at  the  same  time, 
does  not  bring  the  edges  of  the  unsutured  portion  of  the  wound 
so  closely  together  as  to  make  the  insertion  of  the  remaining 
sutures  difficult.  As  soon  as  all  the  deep  sutures  have  been 
inserted  and  tied,  a  further  row  of  superficial  sutures,  including 
the  peritoneum  and  a  small  piece  of  the  muscle,  are  inserted 
between  them  in  order  to  bring  the  peritoneal  edges  exactly 
together.  Any  haemorrhage  from  the  needle  holes  can  be  checked 
by  exerting  for  a  few  moments  firm  pressure  on  the  bleeding-point 
with  a  sponge  wrung  out  of  hot  water.  The  method  of  suturing 
recommended  by  Sanger,  in  which  small  flaps  of  peritoneum  were 
made  along  each  edge  of  the  wound,  in  order  that  by  bringing 
these  flaps  together  a  sero-serous  union  might  be  obtained  over 


1046  OBSTETRICAL  OPERATIONS 

the  incision,  is  unnecessary,  and  has  been  generally  abandoned. 
It  takes  a  considerable  amount  of  additional  time  to  form  the 
flaps,  and  it  is  not  improbable  that  the  presence  of  sero-serous 
instead  of  muscular  union  along  a  portion  of  the  thickness  of  the 
wound  may  lead  to  a  weaker  cicatrix  than  would  otherwise  be 
the  case. 

As  soon  as  the  uterine  suture  is  complete  and  all  haemorrhage 
from  the  incision  has  ceased,  the  peritoneal  cavity  is  cleansed, 
all  clots,  etc.,  being  carefully  removed,  and  the  uterus  is  returned. 
Kelly  recommends  that  instead  of  following  the  usual  course  and 
drawing  down  the  omentum  beneath  the  abdominal  incision,  it 
should  be  drawn  down  behind  the  uterus  in  such  a  manner  as  to 
shut  off  the  intestines  from  the  uterine  incision.  This  has  the 
advantage  of  isolating  the  intestines  in  cases  in  which  subsequent 
infection  of  the  wound  area  occurs,  but  it  has  the  disadvantage 
that  it  increases  the  likelihood  of  adhesions  forming  between  the 
uterus  and  the  abdominal  wall,  and  as  the  uterus  involutes  and 
shrinks  back  into  the  pelvis,  these  may  give  rise  to  distortion 
of  the  organ.  It  is  a  prudent  precaution  to  adopt  in  cases  in 
which,  owing  to  the  previous  course  of  labour,  there  is  any  reason 
to  think  that  infection  is  likely  to  occur,  but,  if  we  believe  that 
perfect  asepsis  has  been  maintained,  we  prefer  the  more  usual 
plan  of  drawing  down  the  omentum  beneath  the  abdominal 
incision. 

The  final  step  of  the  operation  is  the  suture  of  the  abdominal 
wound.  In  all  cases  of  cceliotomy  we  prefer  Kelly's  method  of 
suturing,  using  catgut  for  the  peritoneum  and  silk-worm  gut  for 
the  fascia  and  the  superficial  sutures.  The  abdominal  wound 
is  dressed  in  the  usual  manner  with  a  dry  sterilised  dressing, 
which  is  kept  in  place  with  strips  of  strapping  and  an  abdominal 
binder. 

In  some  cases,  it  is  advisable  to  prevent  the  occurrence  of 
future  pregnancies  on  account  of  the  danger  attached  to  them. 
As  the  removal  of  the  ovaries  is  an  undesirable  expedient,  and  one 
on  which  unpleasant  after-effects  are  consequent,  the  usual  method 
consists  in  interrupting  the  passage  through  the  Fallopian  tubes. 
The  older  methods  of  applying  a  single  ligature  round  each  tube, 
or  even  a  double  ligature  and  excising  the  included  portion,  have 
been  proved  to  be  insufficient,  as  the  ligatures  become  absorbed 
and  the  tubal  lumen  restored.  The  most  reliable  method  is 
that  recommended  by  Whitridge  Williams,  which  consists  in 
ligaturing  and  dividing  the  uterine  ends  of  the  tubes,  then 
excising  the  interstitial  portion  traversing  the  uterine  wall,  and 
finally  bringing  the  edges  of  the  resultant  gap  together  with 
sutures. 

Radical  Cesarean  Section.  —  The  operation  of  radical 
Cesarean  section  consists  in  the  removal  of  the  foetus  from  the 
uterus  in  the  manner  just  described,  followed  by  the  removal  of 


RADICAL  C/ESAREAN  SECTION  1047 

the    uterus    either   supravaginally    or   completely.      Under   this 
heading  three  operations  must  be  discussed  : — 

(a)  The  classical  Porro-Caesarean  operation. 

(b)  Partial  hysterectomy. 

(c)  Complete  hysterectomy. 

The  Classical  Porro-Caesarean  Operation. — The  classical  Porro- 
Caesarean  operation  consists  in  the  removal  of  the  fcetus  through 
an  incision  in  the  anterior  uterine  wall,  as  in  the  conservative 
operation  ;  the  arrest  of  haemorrhage  by  the  application  of  the 
noose  of  a  serre-nceud  round  the  upper  part  of  the  cervico-uterine 
junction  ;  the  amputation  of  the  body  of  the  uterus  above  the 
noose  ;  and  the  fixation  of  the  stump  thus  left  in  the  lower  angle 
of  the  abdominal  wound.  This  operation  is  now  practically  never 
performed,  for  the  reasons  mentioned  at  the  commencement  of 
this  chapter.  It  possesses  one  advantage,  namely,  that  it  is 
slightly  more  rapid  than  any  other  method  of  dealing  with  the 
uterus  after  the  removal  of  the  fcetus,  and  consequently  it  may 
be  of  value  in  cases  in  which  the  patient  is  much  exhausted  by 
previous  haemorrhage.  We  do  not  consider  it  necessary  to 
describe  the  operation  at  any  length,  and  shall  enumerate  only 
its  successive  steps.     These  are  as  follows  : — 

(1-3)  These  steps  are  identical  with  the  first  three  steps  of 
the  conservative  operation. 

(4)  The  broad  ligaments  are  tied  on  each  side  between  the 
ovaries  and  the  uterus,  or  outside  the  ovaries  if  it  is  desired  to 
remove  the  latter,  and  divided.  The  bladder  is  pushed  down  off 
the  anterior  face  of  the  uterus. 

(5)  The  wire  noose  of  a  serre-nceud — an  instrument  resembling 
an  ecraseur — is  passed  over  the  uterus  and  pushed  downwards 
until  it  comes  to  lie  over  the  lower  zone  of  the  latter  The  noose 
is  then  tightened  until  it  firmly  compresses  the  tissues  included 
in  its  grasp. 

(6)  The  body  of  the  uterus  is  then  cut  away,  about  an  inch 
above  the  noose.  If  there  is  any  further  haemorrhage,  the  noose 
is  tightened. 

(7)  Two  specially  made  pins,  with  guarded  ends,  are  then 
passed  transversely  through  the  stump  just  above  the  wire. 
These  pins  lie  on  the  abdominal  wall,  and  support  the  stump  in 
such  a  manner  that  the  noose  is  outside  the  peritoneum. 

(8)  The  abdominal  wound  is  closed,  care  being  taken  to  unite 
the  peritoneum  carefully  round  the  stump.    . 

Partial  Hysterectomy  with  Retro-Peritoneal  Treatment  of  the 
Stump. — In  this  operation  the  uterus  is  removed  supravaginally, 
and  the  pelvic  peritoneum  brought  together  over  the  stump  in 
such  a  manner  as  to  place  the  latter  outside  the  peritoneal  cavity. 
As  performed  in  the  case  of  the  pregnant  uterus,  it  differs  little 
from  the  operation  performed  in  the  case  of  a  large  myomatous 
uterus,  and,  consequently,  it  is  only  necessary  to  enumerate  its 
successive  steps,  as  full    descriptions   of  the    operation  will    be 


1048  OBSTETRICAL  OPERATIONS 

found  in  works  on  gynaecology.  It  is  the  modern  counterpart  of 
Porro's  operation,  and  is  adopted  in  all  cases  in  which  it  is  impos- 
sible or  inadvisable  to  allow  the  uterus  to  remain,  and  in  which 
complete  hysterectomy  is  not  indicated.  The  different  steps  are 
as  follows:  — 

(1-3)  These  steps  are  identical  with  the  first  three  steps  of  the 
conservative  operation. 

(4)  Ligation  of  the  ovarian  vessels  and  the  round  ligament  on 
each  side,  keeping  either  inside  or  outside  the  ovaries  according 
as  we  desire  to  leave  or  to  remove  the  latter. 

(5)  Detachment  of  the  vesico-uterine  fold  of  peritoneum  from 
side  to  side  and  pushing  it  well -down  so  as  to  completely  strip 
the  bladder  off  the  uterus. 

(6)  Similar  detachment  of  a  flap  of  peritoneum  off  the  posterior 
surface  of  the  uterus. 

(7)  Ligation  of  the  uterine  vessels  on  each  side. 

(8)  Amputation  of  the  uterus  just  above  the  vaginal  insertion. 

(9)  Coaptation  by  suture  of  the  divided  edges  of  the  cervix, 
and  control  of  all  bleeding  vessels. 

(10)  Suture  of  the  flap  of  peritoneum  which  was  stripped  off 
the  anterior  uterine  wall  to  the  posterior  flap. 

(11)  Closure  of  the  abdominal  wound. 

Complete  Hysterectomy. — Complete  hysterectomy  only  differs 
from  the  operation  just  described  in  that,  instead  of  amputating 
the  uterine  body,  an  opening  is  made  into  the  posterior  vaginal 
vault  through  the  floor  of  Douglas'  pouch,  the  vaginal  walls  are 
divided  all  round  with  scissors,  and  the  entire  uterus  and  cervix 
thus  set  free  are  removed.  It  is  an  operation  which  is  rarely 
required,  and  which  is  rendered  comparatively  easy  by  the  fact 
that  the  laxity  of  the  pelvic  floor  allows  the  uterus  to  be  drawn 
almost  completely  out  of  the  peritoneal  cavity,  and  so  permits 
more  easy  access  to  the  vaginal  insertion  of  the  cervix  than  in  the 
case  of  a  myomatous  uterus. 

After-treatment. — The  after-treatment  of  Caesarean  section  is 
identical  with  the  after-treatment  of  abdominal  cceliotomy  for 
any  other  purpose.  The  abdominal  sutures  are  removed  on  the 
eighth  day,  and  the  patient  may  be  allowed  out  of  bed  about 
the  fourteenth  to  the  twenty-first  day  provided  convalescence  has 
proceeded  normally.  No  special  treatment,  such  as  vaginal  or 
uterine  douching,  is  indicated  so  long  as  the  lochia  remain  healthy. 

Prognosis.  —  Since  the  introduction  of  the  Sanger  operation, 
the  prognosis  of  Caesarean  section  has  steadily  improved  pari  passu 
with  improvements  in  the  technique  of  abdominal  surgery  and 
the  introduction  of  asepsis.  Williams  records  the  results  of  335 
collected  cases  in  which  the  conservative  operation  was  performed 
in  different  Continental  and  American  clinics.  Out  of  this  number, 
twenty-three  women  died,  a  percentage  of  6-87,  and  this  percentage 
can  be  further  reduced  to  406  if  the  patients  who  were  infected 
prior  to  the  performance  of  the  operation  are  excluded.     The 


SYMPHYSIOTOMY  1049 

mortality  after  the  radical  operation  is  naturally  higher  as  a  result 
of  the  complication  which  necessitated  the  removal  of  the  uterus. 
The  chief  cause  of  a  high  rate  of  mortality  after  Caesarean  section, 
next  to  want  of  asepsis,  is  hesitation.  The  nervous  operator  who 
desires  to  give  the  patient  every  chance  of  delivering  herself,  or  who 
makes  every  effort  to  deliver  her  per  vias  natuvales,  in  spite  of  the 
fact  that  his  judgment  tells  him  that  such  a  course  is  impossible, 
will  have  a  very  high  death-rate,  for  the  obvious  reason  that  many 
of  his  patients  are  infected  before  the  operation,  while  others  are 
too  exhausted  to  stand  the  shock  of  the  operation.  The  more 
frequently  an  operator  has  to  perform  the  operation,  the  lower 
will  be  the  mortality,  not  alone  because  he  has  acquired  special 
skill,  but  because  he  will  not  hesitate  to  operate  early  in  labour 
on  the  cases  that  require  operation.  Once  it  is  recognised  that 
delivery  of  a  living  child  per  vias  natuvales  is  impossible,  and  it  is 
determined  to  perform  Caesarean  section,  no  further  vaginal  ex- 
aminations or  manipulations,  other  than  a  single  vaginal  douche, 
should  be  allowed.  The  essentials  for  good  results  are  asepsis, 
early  operation,  and  rapidity  from  the  commencement  of  the 
uterine  incision  to  the  tying  of  the  uterine  sutures.  After  that, 
the  completion  of  the  operation  may  be  performed  with  delibera- 
tion, and  sufficient  time  spent  to  ensure  perfect  haemostasis  and 
coaptation  of  the  abdominal  wound. 


SYMPHYSIOTOMY 

Symphysiotomy  is  the  term  applied  to  the  division  of  the  liga- 
ments of  the  symphysis  pubis  with  the  object  of  permitting  the 
innominate  bones  to  separate,  and  so  of  enlarging  the  diameters 
of  the  pelvis. 

The  operation  of  symphysiotomy  is  said  to  have  been  performed 
for  the  first  time  by  De  la  Courrue*  in  1654,  but  it  was  not  until 
its  revival  de  novo  by  Sigault  in  1768  that  it  can  be  considered  to 
have  been  brought  to  the  notice  of  medical  men.  Hull  I  gives  an 
interesting  account  of  its  reception  : — •'  No  discovery  in  the  healing 
art  was  ever  announced  with  so  much  eclat.  It  was  proposed  by 
M.  Sigault  in  the  year  1768,  to  the  Royal  Academy  of  Surgery  at 
Paris.  But  the  report  of  M.  Ruffel,  who  was  appointed  to  inquire 
into  the  merits  of  the  operation,  being  unfavourable,  it  did  not 
receive  the  countenance  or  sanction  of  that  respectable  body. 
Notwithstanding  this  discouragement  to  his  project,  M.  Sigault 
determined  to  put  it  in  execution,  as  soon  as  a  favourable  oppor- 
tunity should  occur,  and  it  was  first  practised  by  this  physician, 
with  the  assistance  of  M.  le  Roy,  in  Paris,  on  the  first  of  October, 
1777,  upon  the  wife  of  a  soldier  named  Souchot,  who,  out  of  four 

*   Vide  Siebold,   E.  C.  J.  :    '  Abbildungen  aus   der   Geburtschulfe,'   Berlin, 
1829,  S.  238. 
f  Op.  cit. ,  p.  92. 


1050 


OBSTETRICAL  OPERATIONS 


children,  had  not  been  able  to  bring  one  into  the  world  alive. 
Although  the  urethra  was  wounded  in  the  operation,  the  vesica 
urinaria  materially  injured,  and  the  poor  woman's  life  greatly 
endangered,  the  Faculty  of  Medicine  at  Paris,  on  the  report  of 
Granclas  and  Descemet  (two  of  their  members,  who  had  been 
deputed  to  attend  to  the  case)  and  a  view  of  the  woman,  without 
waiting  for  further  experience,  immediately  caused  a  medal  to  be 
struck  in  honour  of  the  inventor ;  and  the  French  Government 
rewarded  both  the  operator  and  his  patient  with  a  pension.  .  .  . 
The  operation  was  supposed  to  be  capable  of  superseding  not 
only  the  Cassarean  operation  and  the  crotchet,  but  even  the  use 
of  the  forceps,  and  every  obstetrical  instrument  whatever.'  Hull, 
who  was  a  strong  opponent  of  the  operation,  was  able  to  collect 
the  results  of  forty-four  cases  of  symphysiotomy  performed  between 


Fig.  440. — Horizontal    Section   through   the   Right  Sacro-iliac  Joint 
of  a  Pelvis  on  which  Symphysiotomy  has  been  performed. 

si,  Relaxed  sacro-iliac  ligaments;  p,  periosteum,  which  has  detached  as 
the  pelvic  bones  separated.     (Faraboeuf. ) 

1777  and  1800,  of  which  thirty  women  survived  and  fourteen  died. 
Fifteen  children  were  saved,  while  twenty-two  were  born  dead  or 
died  immediately  after  birth.  Subsequent  to  1800,  the  operation 
appears  to  have  been  practically  abandoned,  '  being,'  as  Hull  says, 
'  no  longer  recommended  by  any  practitioner,  who  has  seen  it 
performed,  and  attended  to  its  consequences.' 

The  operation  was  revived  in  1866  by  Morisani  of  Naples, 
and  this  operator  was  able  to  report  to  the  International  Medical 
Congress,*  in  1881,  fifty  operations  with  forty  recoveries.  Since 
that  time,  its  former  history  has  been  repeated,  and  it  has  been 
the  subject  of  condemnation  and  approval.  At  the  present  time, 
its  position  is  fairly  generally  recognised,  its  indications  and 
limitations  made  clear,  and,  on  the  whole,  in  spite  of  many 
opponents,  it  may  be  said  to  hold  the  place  to  which  it  is  entitled, 
as  an  operation  which  at  times  is  of  considerable  value. 

*  '  De  la  symphyseotomies  Annates  de  Gyn.  et  d'Obst.,  1881,  xvi.,  444,  445. 


EFFECT  OF  SYMPHYSIOTOMY  ON  THE  PELVIS 


1051 


Effect  of  Symphysiotomy  on  the  Pelvis. — The  result  of  division 
of  the  inter-pubic  ligaments  is  that  the  pubic  bones  spring  apart 
under  the  influence  of  the  pull  of  the  posterior  sacro-iliac  liga- 
ments upon  the  posterior  limb  of  the  iliac  lever.  Two  results 
follow  from  this.  All  the  diameters  of  the  pelvic  brim  are  in- 
creased in  length,  and  a  gap  occurs  between  the  ends  of  the  pubic 
bones,  into  which  gap  a  part  of  the  circumference  of  the  head  is 
able  to  bulge.  Thus,  not  only  is  the  size  of  the  pelvis  directly 
increased  by  the  lengthening  of  its  diameters,  but  it  is  indirectly 
increased   by  the   occurrence   of  this   gap.     The  extent   of  the 


Ni   S 


Fig.  441. — Diagram  of  Pelvic  Brim  showing  the  Gain  in  Space  on 
Opening  the  Symphysis. 

PS,  Conjugate  of  brim  when  the  pelvis  is  closed  ;  PS',  conjugate,  after 
symphysiotomy  has  been  performed,  bones  6  cms.  apart.     (Wehle.) 

increase,  which  takes  place  in  the  diameters,  depends  on  the 
extent  to  which  the  pubic  bones  are  separated,  and  the  initial 
size  of  the  pelvis,  and  of  these  the  former  is  the  more  important 
factor.  The  average  amount  of  separation  of  the  •  bones  is 
about  6  cms.,  and  this  yields  an  average  increase  in  the  true 
conjugate  of  1-5  cms.  (f  in.).  The  greatest  amount  that  has 
been  obtained  without  causing  injury  to  the  sacro-iliac  articula- 
tions is  9  cms.,  yielding  an  increase  in  the  true  conjugate  of 
a  little  over  2  cms.  (±  in.).  The  limit  of  separation  which  is 
permissible,   and  which    should   not   be   exceeded,  is,   however, 


1052 


OBSTETRICAL  OPERATIONS 


usually  stated  to  be  7  cms.  The  effect  of  the  initial  size  of  the 
pelvis  on  the  increase  produced  in  the  diameters  by  a  given 
degree  of  separation  of  the  bones  is  in  inverse  proportion  to  the 
initial  size.  The  larger  the  pelvis,  the  less  is  the  increase  in  the 
diameters ;  the  smaller  the  pelvis,  the  greater  is  the  increase. 
The  indirect  increase  produced  by  the  gap  between  the  bones  is 
estimated  by  Morisani  to  be  one  centimetre  in  cases  in  which  the 
separation  of  the  bones  is  6*5  cms.,  and  in  which  one  parietal 
eminence  bulges  into  the  gap. 

A  further  cause  of  increase  in  the  diameters  must  be  men- 
tioned— namely,  the  effect  of  the  downward  movement  of  the 
pubic  bones  as  they  separate.  This  movement  is  identical  with 
that  which  occurs  when  the  patient  is  placed  in  Walcher's 
position.  According  to  Sandstein,  Walcher's  position  causes  an 
average  descent  of  the  pubic  bones  at  the  symphysis  of  5  mm., 
and  symphysiotomy  with  6  cms.  separation  of  the  bones  an 
average  descent  of  8 '4  mms. 

The  following  table  was  drawn  up  by  Farabceuf  to  show  the 
combined  effects  of  the  foregoing  factors  on  pelves  of  different 
sizes,  in  which  different  degrees  of  separation  of  the  pubic  bones 
had  been  obtained  :  — 


Interval 
between 
the  Bones. 

Increase  in  the  C.V.  in  the  case  of  a  Pelvis  measuring 
in  that  Diameter 

originally 

5  cms. 

6  cms. 

7  cms. 

8  cms. 

9  cms. 

10  cms. 

5  cms.  - 

23  mms. 

21  mms. 

19  mms. 

17  mms. 

16  mms. 

14  mms. 

6     ,,     - 

29      .. 

26     „ 

23      ., 

21 

19       M 

18      ,, 

7     ..     - 

34      .. 

31      .. 

28      ,, 

25      .. 

23      .. 

21      ,, 

It  must  not  be  thought  that  the  antero  -  posterior  pelvic 
diameters  alone  are  affected  by  symphysiotomy,  as  all  the  other 
diameters  are  similarly  affected  even  to  a  greater  extent.  Thus, 
the  increase  in  the  oblique  diameters  is  once  and  a  half  as  much 
as  is  that  in  the  conjugate,  and  in  the  transverse  about  twice  as 
much. 

Perhaps  the  following  statement  made  by  Farabceuf*  will  give  a 
more  immediately  obvious  impression  of  the  alteration  in  the  size 
of  the  pelvis  produced  by  symphysiotomy  than  will  the  foregoing 
figures: — A  pelvis,  having  a  minimum  sacro-pubic  measurement 
of  8  cms.  (3^  ins.),  in  which  the  symphysis  is  divided  and  the  bones 
separated  to  the  extent  of  6  cms.  (2-f  ins.),  will  allow  a  sphere  of 
9-8  cms.  (4  ins.  approximately,  equal  to  a  very  large  foetal  head) 
to  pass  through,  whilst  when  intact  it  would  only  admit  a  sphere 

*  '  La  Symphyseotomie,  Anatomie,  Instrumentation  et  Technique  du  Pro- 
fesseur  Farabceuf,'  by  P.  A.  Lop,  Gazette des  Hop.,  1895,  Nos.  47,  50,  53.  Also 
'  Precis  de  Medecin  Operatoire,'  4th  edition,  1895. 


INDICATIONS  FOR  SYMPHYSIOTOMY  1053 

of  8  cms.  diameter  (a  small  foetal  head)  (v.  Fig.  442).  The 
benefit  derived  from  the  operation  will  be  the  more  appreciated 
when  we  recollect  that  the  capacity  of  the  first  sphere  is  almost 
double  that  of  the  second.  In  other  words,  a  foetus  of  3,000  grms. 
(6  lbs.  10  ozs.)  is  smaller  in  relation  to  a  divided  pelvis  than  is  a 
foetus  of  2,000  grms.  (4  lbs.  6  bzs.)  to  the  same  pelvis  prior  to 
division.  Again,  take  the  case  of  a  pelvis  with  a  sacro-pubic 
diameter  of  6  cms.  instead  of  8  cms.,  and  with  a  similar  pubic 
separation  of  6  cms.  In  such  a  case,  the  diameter  of  the  sphere 
admitted  after  symphysiotomy  will  be  8-4  cms.,  while  prior  to 
section  it  was  6  cms.,  and  in  capacity  the  first  sphere  will  be 
almost  treble  the  second. 

Indications. — The  principal  indication  for  the  performance  of 
symphysiotomy  is  a  certain  degree  of  pelvic  contraction.     Accord- 


Fig.  442. — Diagram  showing  the  Manner  in  which  the  Head  Bulges 
between  the  separated  pubic  bones,  and  the  relative  slzes 
of  the  Spheres  which  will  pass  through  before  and  after 
Symphysiotomy.     (Farabceuf.) 

ing  to  Morisani,  the  minimum  antero-posterior  diameter  in  which 
symphysiotomy  is  permissible  is  7  cms.  (2-i  ins.).  This  figure  is 
based  on  the  assumption  that  the  average  amount  of  permissible 
separation  of  the  bones  gives  an  increase  in  the  conjugate  of 
1 -5  cms.  (|  ins.),  and  that,  by  the  protrusion  of  one  parietal 
eminence  into  the  gap,  a  further  increase  of  a  centimetre  is 
obtained.  If  the  average  length  of  the  bi-parietal  diameter  of  the 
head  is  taken  to  be  9-5  cms.  (3f  ins.),  it  will  be  seen  that  such  a 
head  will  just  fit  into  a  pelvis  with  an  original  conjugate  of 
7  cms.,  enlarged  by  the  addition  of  2^5  cms. 

If  the  operation  is  permissible  in  cases  in  which  the  obstruction 
is  due  to  pelvic  contraction,  it  follows  that  it  is  also  permissible 
in  cases  in  which  the  obstruction  is  due  to  excessive  size  of  the 


io54 


OBSTETRICAL  OPERATIONS 


otherwise  normally  developed  head,  or  in  cases  in  which  the  head 
has  become  impacted  in  a  malpresentation,  which  cannot  be 
corrected,  and  cannot  be  delivered  by  the  forceps.  We  are  not, 
however,  aware  that  the  operation  has  been  performed  under 
such  circumstances,  a  fact  which  is  probably  due  to  the  difficulty 
of  recognising  that  delivery  is  impossible  until  labour  has  been  so 
long  in  progress  that  the  death  of  the  foetus  has  occurred. 

So  far  as  contracted  pelvis  is  concerned,  we  thus  see  that 
symphysiotomy  is  an  alternative  in  the  higher  degrees  of  pelvic 
contraction  to  Csesarean  section,  in  the  lower  degrees  to  pre- 
mature labour  and  version.     The  induction  of  premature  labour 


Fig.  443. — Farabceuf's  Knife  for  Dividing  the  Symphysis  Pubis. 

can  scarcely  be  regarded  as  an  alternative.  It  is,  in  our  opinion, 
the  correct  treatment  to  adopt  if  the  case  is  seen  in  time  ;  but, 
even  if  it  is  adopted,  the  advisability  of  symphysiotomy  may  still 
become  a  matter  for  discussion  in  cases  in  which  the  head  does 
not  pass  through  the  brim,  though,  if  a  correct  estimate  is 
made  of  the  relative  sizes  of  the  fcetal  head  and  the  pelvis,  such 
cases  will  not  occur.  If  the  patient  is  not  seen  in  time,  the 
induction  of  premature  labour  is,  necessarily,  not  a  possible  mode 
of  treatment.  Prophylactic  version  and  symphysiotomy,  on  the 
other  hand,  are  directly  competing  lines  of  treatment,  for,  if  the 


Fig.  444. — Galbiati's  Sickle-shaped  Knife  for  Dividing  the 
Symphysis  Pubis. 


former  is  adopted  and  fails,  it  is  too  late  to  perform  the  latter. 
We  have  already  referred  to  the  relative  position  of  the  two 
procedures  when  discussing  the  treatment  of  contracted  pelvis.* 
Prophylactic  version  is  contra-indicated  in  general  contraction, 
and  symphysiotomy  or  Cesarean  section  is  preferable.  In  flattened 
pelvis,  much  depends  on  the  individual  operator,  but,  if  prophy- 
lactic version  has  failed  to  procure  a  living  child  in  former 
labours,  some  alternative  method  should  be  tried,  and  here  again 
a  choice  must  be  made  between  the  operations  just  named. 
Caesarean  section  is  a  simpler  operation,  and  can  be  more  safely 
performed  by  a  comparatively  unskilled  operator.  It  requires 
fewer  assistants,  and  convalescence  is  more  rapid.     For  these 

*   Vide  Part  VII.,  Chap.  II.,  p.  730. 


INSTRUMENTS  NECESSARY  FOR  SYMPHYSIOTOMY        1055 

reasons  we  believe  that  it  will  always  be  the  more  popular  opera- 
tion, though  under  certain  circumstances,  especially  in  hospital 
practice,  symphysiotomy  may  be  preferable.  One  very  great 
advantage,  which  the  latter  operation  has  over  Caesarean  section, 
is  that  it  may  cause  a  permanent  increase  in  size  in  the  pelvis, 
even  in  cases  in  which  recovery  is  perfect.  We  have  seen  a 
patient  at  the  Rotunda  Hospital,  on  whom  Smyly  had  per- 
formed symphysiotomy  in  a  previous  pregnancy  owing  to  other 
means  having  already  failed  to  obtain  a  living  child,  deliver 
herself  of  a  living  infant.  Caesarean  section,  on  the  other  hand, 
owing  to  the  possible  weakening  of  the  uterine  wall  in  the  neigh- 
bourhood of  the  incision,  always  leaves  the  patient  in  a  slightly 
more  unfavourable  state,  so  far  as  future  pregnancies  are  con- 
cerned, than  she  was  before  the  operation  was  performed. 


Fig.  445.- — Farabceuf's  Grooved  Sound  for  Protecting  the  Tissues 
behind  the  symphysis  during  section  of  the  joint. 

There  are  certain  cases  in  which,  in  our  opinion,  symphysio- 
tomy is  definitely  indicated  and  in  which  there  is  no  alternative 
treatment  if  the  life  of  the  foetus  is  to  be  saved,  namely,  in  those 
cases  in  which  labour  has  been  in  progress  for  a  considerable 
time,  the  forceps  have  failed  to  effect  delivery,  and  the  foetus  is 
alive.  Under  such  circumstances,  Caesarean  section  is  contra- 
indicated,  and  craniotomy  is  the  only  alternative. 

Instruments. — The  following  instruments  are  required  : — Two 
scalpels,  two  pairs  of  scissors,  two  lateral  retractors  for  the 
edges  of  the  incision,  stout  whole-curved  needles  of  different 
sizes,  needle-holder,  a  dozen  clip  forceps,  several  straight  and 
curved  narrow-bladed  clamps,  metal  catheter,  dissecting  forceps 
with  teeth,  suture  materials,  iodoform  gauze,  and  the  usual  gauze 
sponges  and  dressings.  In  addition  to  this  list,  the  following  in- 
struments are  an  assistance,  though  they  are  not  indispensable  : — 
A  special  knife  for  dividing  the  symphysis,  either  sickle-shaped 
as  recommended  by  Galbiati,  or   Farabceuf's  knife — a  bistoury 


1056  OBSTETRICAL  OPERATIONS 

with  a  short  strong  blade,  thinner  at  the  edges  than  in  the 
middle  ;  Faraboeuf  s  grooved  sound  ;  and  some  form  of  registering 
separator  for  the  pubic  bones,  such  as  Pinard's. 

Assistants. — Four  assistants  are  essential.  One  assistant  sits 
at  each  side  of  the  patient  to  help  the  operator,  and  to  prevent 
the  innominate  bones  from  springing  apart  with  undue  sudden- 
ness ;  one  manages  the  instruments,  sponges,  and  sutures ;  and 
one  administers  the  anaesthetic. 

Operation. — The  patient  is  placed  on  an  operating  table  in  the 
lithotomy  position,  the  pubes  is  shaved,  and  the  external  skin 
and  the  vagina  washed  and  disinfected  in  the  usual  manner.  If 
the  os  is  not  dilated  sufficiently  to  allow  the  passage  of  the  foetus, 
dilatation  must  be  effected  beforehand  by  means  of  hydrostatic  or 
other  dilators. 

The  steps  of  the  operation  are  as  follows  : — 

(1)  An  incision  is  made  through  the  skin  and  subjacent  tissues, 


Fig.  446. — Pinard's  Separator  for  Measuring  the  Distance  between 
the  Pubic  Bones  after  Symphysiotomy. 

starting  an  inch  and  a  half  above  the  symphysis  and  extending 
downwards  to  a  point  just  above  the  clitoris. 

(2)  The  suspensory  ligament  of  the  clitoris  is  divided,  and  the 
clitoris  is  drawn  downwards  so  as  to  expose  the  outline  of  the 
pubic  arch. 

(3)  A  vertical  incision  of  sufficient  size  to  admit  the  finger  is 
made  through  the  aponeurosis  of  the  recti.  If  necessary,  this 
incision  is  increased  in  length  by  dividing  the  aponeurosis  trans- 
versely on  each  side  of  the  vertical  incision. 

(4)  The  finger  is  introduced  into  this  opening,  and  pushed 
downwards  behind  the  symphysis  until  it  appears  beneath  the 
latter,  and  in  such  a  manner  as  to  detach  the  retro-pubic  struc- 
tures from  the  symphysis.  This  detachment  is  also  carried  out 
laterally  for  an  inch  to  two  inches  at  each  side  of  the  symphysis. 
A  catheter  is  introduced  into  the  urethra,  and  the  latter  pushed 
backwards  and  to  one  side. 

(5)  The  pubic  ligaments  are  cautiously  divided  from  behind 
and  above  downwards  and  forwards,  the  assistants  at  the  same 
time  making  pressure  on  the  sides  of  the  pelvis  to  prevent  the 
innominate  bones  from  springing  apart  suddenly. 


THE  OPERATION  OF  SYMPHYSIOTOMY 


1057 


(6)  The  instrument  for  measuring  the  degree  of  separation  of 
-the  bones  is  introduced  between  the  bones,  and  the  latter  are 

allowed  to  separate  gradually  as  the  assistants  relax  their  pressure 
on  the  sides  of  the  pelvis.  If  a  sufficient  degree  of  separation 
does  not  occur  spontaneously,  the  thighs  are  cautiously  separated, 
if  necessary  with  a  slight  degree  of  force,  until  the  register  shows 
that  the  necessary  degree  of  separation  has  been  obtained.  This 
should  not  exceed  6  cms. 

(7)  The  child  is  extracted  by  the  forceps,  or,  after  version,  by 
traction  on  the  leg  if  the  pelvic  pole  presents. 


Pubis  sym- 
physis 


iji  Frcenum  of  the 

clitoris 


Orifice  of  urethra 


giVX       Vestibule 


Orifice  of  vagina 


Vaginal  bulb 


Venous  plexus 


Fossa  naviculars 


Fig.  447. — The  Symphysis  Pubis  seen  from  in  Front,  showing  the 

Relations  of  the  Crura  of  the  Clitoris. 

(From  Toldt's  '  Anatomy,'  by  permission  of  Messrs.  Rebman.) 


(8)  A  gauze  sponge  is  placed  behind  the  separated  bones  to 
push  back  the  retro-pubic  structures  and  prevent  them  from 
being  nipped  between  the  bones,  and  deep  sutures  of  strong  silk 
traversing  the  whole  thickness  of  the  incision  down  to  and_  in- 
cluding the  periosteum  are  inserted.  A  couple  of  suture  points 
of  silkworm  gut  are  also  inserted  to  bring  together  the  edges  of 
the  divided  aponeurosis.  The  assistants  then  press  together  the 
pelvic  bones,  until  the  edges  of  the  pubic  bones  come  together, 
care  being  taken  that  nothing  intervenes  between  them.     The 

67 


1058  OBSTETRICAL  OPERATIONS 

sutures  in  the  aponeurosis  are  tied  and  cut  short,  and  then  the 
silk  sutures  are  tied.  If  necessary,  a  few  superficial  sutures  are 
inserted  to  bring  the  skin  edges  perfectly  together,  the  gauze 
sponge  behind  the  symphysis  having  been  first  removed. 

(9)  The  wound  is  dressed  with  a  dry  dressing,  and  a  many- 
tailed  binder  is  applied  firmly  round  the  pelvis  in  such  a  manner 
as  to  afford  the  necessary  support  to  the  bones.  Finally,  over 
all,  the  ordinary  abdominal  binder  is  tightly  applied. 

In  making  the  separation  of  the  retro-pubic  tissues,  care  must 
be  taken  to  keep  close  to  the  bone,  in  order  to  avoid  as  far  as 
possible  tearing  the  veins.  If,  after  division  of  the  cartilage  of 
the  joint,  the  bones  do  not  separate,  it  is  usually  due  to  the  fact 
that  some  fibres  of  the  sub-pubic  ligament  have  been  left  un- 
divided. The  exact  position  of  the  symphysis  can  as  a  rule  be 
ascertained  by  palpating  the  joint  with  the  finger,  but  if  there  is 
any  difficulty  in  doing  so,  its  position  can  be  easily  determined 
by  gently  pricking  the  surface  of  the  bones  with  the  point  of  the 
knife,  until  the  lessened  resistance  shows  that  the  knife  is  cutting 
not  bone  but  cartilage.  As  the  bones  separate,  the  finger  should 
be  kept  in  relation  to  the  attachments  of  the  crura  of  the  clitoris 
to  the  descending  rami  of  the  pubes,  and  if  the  crura  become 
so  tense  that  rupture  appears  probable,  they  must  be  further 
separated  from  the  bones.  Forcible  separation  must  always 
be  carried  out  with  extreme  caution,  and,  while  it  is  made,  its 
effect  as  shown  by  the  register  must  be  carefully  watched. 
Similarly,  as  the  head  of  the  infant  is  being  extracted,  and  is 
forcing  the  innominate  bones  still  further  apart,  the  assistants 
must  apply  lateral  counter-pressure  in  order  to  prevent  too  great 
separation.  For  the  same  reason,  traction  must  be  made  slowly 
and  with  caution,  indeed,  some  operators,  and  notably  Zweifel, 
advise  to  leave  delivery  to  the  natural  efforts,  as  such  delivery  is 
more  gradual  than  if  effected  by  the  forceps.  Such  a  course,  how- 
ever, possesses  the  disadvantage  that  it  causes  delay,  and  conse- 
quently is  not  always  practicable. 

From  three  to  four  deep  sutures  are  usually  necessary,  and 
as  there  is  a  considerable  amount  of  strain  upon  them,  it  is 
advisable  to  tie  them  over  lead  plates  in  order  to  prevent  them 
from  cutting  through  the  skin.  Zweifel  recommends  that  a 
drainage  tube  be  always  placed  in  the  gap  left  behind  the  pubes, 
in  order  to  prevent  an  accumulation  of  blood  which  might  be 
subsequently  infected.  If  a  considerable  space  is  left  behind 
the  bones  this  precaution  is  advisable,  but,  if  the  tissues  come 
well  together  and  there  is  not  much  haemorrhage  or  oozing,  we 
doubt  if  it  is  necessary.  If  it  is,  we  prefer  the  use  of  a  drain 
of  iodoform  gauze  instead  of  a  tube.  In  applying  the  dressings 
over  the  incisions,  care  must  be  taken  to  keep  them  quite  separate 
from  the  vaginal  dressings,  as  the  latter  require  to  be  changed 
frequently. 

After-treatment. — The  after-treatment  and  the  nursing  of  the 


THE  PROGNOSIS  OF  SYMPHYSIOTOMY  1059 

patient  is  difficult  and  tedious,  and  constitutes  one  of  the  great 
objections  to  the  operation.  The  patient  must  be  kept  at  rest 
on  her  back,  on  a  firm  bed,  for  three  to  four  weeks,  during 
which  time  the  pubic  bones  are  kept  together  by  a  tight  binder. 
At  the  same  time,  the  usual  nursing  details  of  the  puerperium 
must  be  attended  to,  with  the  addition  that  the  catheter  must 
be  passed  regularly.  When  the  time  comes  to  allow  the 
patient  out  of  bed,  a  properly  fitting  pelvic  belt  should  be  pro- 
vided, and  be  worn  continuously  for  the  twelve  months  after  the 
operation. 

Prognosis. — The  prognosis  of  symphysiotomy,  when  performed 
by  competent  operators,  is  on  the  whole  good.  In  278  cases 
collected  by  Neugebauer,  there  was  a  maternal  mortality  of 
ii'i  per  cent.,  but  this  percentage  has  been  considerably  reduced 
by  others.  Bar  records  140  cases  operated  upon  by  Pinard, 
Zweifel,  and  Kiistner  with  a  mortality  of  6-7  per  cent.,  while 
Zweifel  has  operated  upon  31  cases  without  a  death.  The 
principal  dangers  of  the  operation  are  rupture  of  the  bladder  or 
urethra  during  the  separation  of  the  bones  ;  haemorrhage  from 
the  plexus  of  veins  behind  the  symphysis,  or  from  laceration  of 
the  clitoris  ;  rupture  of  the  sacro-iliac  articulations  ;  failure  to 
obtain  union  between  the  pubic  bones ;  and  septic  infection. 
Such  accidents  occasionally  occur  even  in  the  hands  of  experienced 
operators,  and,  if  the  operation  was  to  be  adopted  by  the  general 
practitioner,  as  has  been  suggested,  they  would  necessarily  be 
of  far  more  frequent  occurrence.  We  do  not  agree  with  the 
opinion  expressed  by  Whitridge  Williams  that  the  present  en- 
thusiasm for  symphysiotomy  will  eventually  disappear,  if  by  this 
he  means  that  the  operation  will  cease  to  be  performed,  but  we 
consider  that  it  is  essentially  an  operation  to  be  performed  by 
the  skilled  specialist,  amidst  the  favourable  surroundings  of  a 
hospital. 


67 — 2 


CHAPTER  V 
CRANIOTOMY  AND  EMBRYOTOMY 

Craniotomy — Instruments — Steps  of  the  Operation  ;  Perforation,  Evacua- 
tion, Compression,  Extraction.  Embryotomy — Decapitation — Eviscera- 
tion- Cleidotomy . 

CRANIOTOMY 

Craniotomy  is  the  term  applied  to  any  cutting  or  crushing 
operation  on  the  head  of  the  foetus  performed  prior  to  delivery 
with  the  object  of  reducing  its  size. 

Indications. — The  operation  of  craniotomy  of  necessity  involves 
the  death  of  the  foetus,  if  this  has  not  already  occurred,  and 
consequently  it  should  never  be  performed  in  the  case  of  a  living 
infant  unless  no  other  means  of  effecting  delivery  can  be  carried 
out,  under  the  circumstances  of  the  case.  It  is  the  duty  of  the 
obstetrician  to  reduce  the  number  of  such  cases  to  the  lowest 
limit,  and  in  recent  years,  in  consequence  of  the  improvements 
which  have  taken  place  in  the  technique  of  Caesarean  section 
and  symphysiotomy,  great  advances  have  been  made  in  this 
direction.  The  operation  cannot  be  performed  unless  the  size  cf 
the  genital  canal  is  sufficient  to  allow  the  passage  of  the  foetus 
after  reduction  in  size.  It  is,  in  consequence,  contra-indicated 
in  all  cases  in  which  there  is  absolute  pelvic  contraction,  that  is, 
contraction  in  which  the  conjugate  measures  less  than  i\  inches 
in  the  case  of  a  flat  pelvis,  or  than  o.\  inches  in  the  case  of  a 
generally  contracted  pelvis.  It  is  true  that  a  mutilated  foetus  has 
been  extracted  through  a  pelvis  even  smaller  than  this,  but  the 
dangers  associated  with  such  an  operation  are  greater  than  those 
associated  with  Caesarean  section.  The  performance  of  cranio- 
tomy is  also  inadvisable  or  impossible  in  the  case  of  pelves 
markedly  deformed  by  the  presence  of  tumours,  or  when  the 
vagina  is  rendered  undilatable  owing  to  the  presence  of  old 
cicatrices.  We  thus  see  that  the  operation  is  one  which  possesses 
only  a  limited  range  of  applicability.  It  is  unnecessary  when 
there  is  only  slight  disproportion  between  the  pelvis  and  the 
foetus.     It  is  never  the  operation  of  choice  in  the  presence  of  a 

1060 


CRANIOTOMY 


1061 


living  foetus.     It  is  impossible  when  the  disproportion  between 
the  size  of  the  foetus  and  the  pelvis  exceeds  certain  limits. 
Craniotomy  is  indicated  under  the  following  conditions  : — 

(1)  It  is  absolutely  indicated  if  the  foetus  is  dead,  and  if  the 
extraction  of  the  undiminished  head  is  either  dangerous  or 
impossible. 

(2)  It  is  relatively  indicated  if  there  is  a  relative  indication 
present  for  the  performance  of  Caesarean  section  or  symphy- 
siotomy, but  the  patient  refuses  to  allow  such  an  operation. 


Fig.  448. — Simpson's  Perforator. 

Instruments. — The  following  special  instruments  are  required 
for  craniotomy  : — An  instrument  for  perforating  the  head,  such 
as  Simpson's  perforator,  or  Smellie's  scissors.  An  instrument 
for  washing  out  the  brain  from  the  perforated  head,  such  as  a 
large-sized  Bozemann's  catheter.  An  instrument  for  crushing 
and  extracting  the  perforated  head,  such  as  a  cranioclast,  a 
cephalotribe,  Winter's  modification  of  Auvard's  combined  cranio- 
clast and  cephalotribe,  or  Simpson's  basilyst.  Personally,  we 
consider  that  the  two  instruments  most  suitable  for  perforation, 
crushing  and  extraction  are  Simpson's  perforator  and  Winter's 
modification  of  Auvard's  combined  instrument,  but  each  indi- 
vidual operator  will  be  largely  guided  by  his  own  past  experience 


Fig.  449. — Braun's  Cranioclast. 

or  by  the  experience  of  his  teachers.  Simpson's  perforator 
possesses  the  advantage  over  Smellie's  scissors  that  it  can  be 
used  by  the  operator  without  assistance,  while  the  scissors 
requires  three  hands  to  work  it, — one  hand  to  hold  it  in  position 
outside  the  vulva,  one  hand  to  keep  it  in  position  against  the  head 
of  the  foetus,  and  a  third  hand  to  help  the  first  hand  to  separate 
the  blades. 


1062 


OBSTETRICAL  OPERATIONS 


All  forms  of  crushing  and  extraction  instruments  are  more  or 
less  based  on  the  cranioclast  and  the  cephalotribe.  The  cranioclast 
is  a  two-bladed  instrument,  with  concavo-convex  blades  so  adapted 
to  one  another  that  their  curves  correspond  (v.  Fig.  449).  One 
blade  is  applied  inside  the  skull,  the  other  blade  outside.  In 
consequence,  it  is  admirably  adapted  for  seizing  and  pulling  upon 
the  head  without  slipping.  It  causes  an  elongation  in  the  shape  of 
the  head,  and  consequently  a  compensatory  diminution  in  the  other 
diameters,  as  shown  in  Fig.  450.  It  is,  however,  obviously  unsuited 
for  producing  a  marked  diminution  in  the  base  of  the  skull,  as  it 


Fig.  450. — Diagram  showing  the  Effect  of  Traction  with  a 
Cranioclast  on  a  Perforated  Head. 


cnly  compresses  one  lateral  wall,  and  not  the  entire  base.  The 
cephalotribe  is  also  two-bladed,  with  concavo-convex  blades,  but 
they  are  so  adapted  that  the  curves  are  opposed  to  one  another, 
as  in  the  case  of  the  forceps,  and  both  blades  are  applied  outside 
the  head  (v.  Fig.  451,  B).  Consequently,  it  is  well  suited  for 
crushing  the  base'  of  the  skull,  as  it  includes  the  entire  base 
between  its  blades.  It  is,  however,  a  bad  extractor,  as  it  tends 
to  slip.  To  compress  sufficiently,  the  curve  of  its  blades  must 
be  slight,  otherwise  there  would  be  too  much  space  between 
them.  To  extract  without  slipping,  the  curve  must  be  so  pro- 
nounced that  it  grips  the  head  as  does  a  forceps. 

As  both  the  cranioclast  and  the  cephalotribe  thus  possess 
complementary  qualities,  it  is  not  strange  that  many  attempts 
have  been  made  to  produce  a  satisfactory  combination  of  them._ 


CRANIOTOMY 


1063 


Auvard's  combined  instrument  is,  as  its  name  shows,  practically 
the  two  instruments  in  one.  Two  blades  form  a  cranioclast  with 
which  the  head  is  seized  and  held  firmly,  the  third  blade  forms  a 
cephalotribe  in  conjunction  with  the  other  two.  As  modified  by 
Winter,  it  is  the  instrument  of  which  we  have  the  most  experience, 
and    we   consider    that    it    is   admirably    suited    to   its    purpose. 


Fig.  451. — A,  Winter's  Modification  of  Auvard's  Combined  Cranio- 
clast and  Cephalotribe  ;  B,  Braxton  Hicks'  Cephalotribe. 

Simpson's  basilyst  differs  from  it,  in  that  instead  of  crushing  the 
head  from  without  as  with  a  cephalotribe,  it  rends  the  base  of 
the  skull  apart  from  within,  and  then  grasps  the  broken-up  head 
with  a  cranioclast  grip.  We  have  no  experience  of  this  instru- 
ment, but  in  Simpson's  hands  it  has  proved  most  satisfactory.* 
*  Trans.  Edinburgh  Obstet.  Soc,  vol.  xxv.,  p.  86. 


1064 


OBSTETRICAL  OPERATIONS 


Conditions. — Certain  conditions  must  be  fulfilled  before  cranio- 
tomy can  be  performed  : — 

(1)  The  pelvis  must  be  of  sufficient  size  to  allow  the  passage 
of  the  mutilated  foetus.  In  the  case  of  a  flattened  pelvis,  the 
true  conjugate  must  measure  at  least  o.\  inches,  in  the  case  of  a 
generally  contracted  pelvis  at  least  i\  inches. 

(2)  The  uterine  orifice  must  be  sufficiently  dilated  to  permit  the 
necessary  manipulations. 

(3)  The  head  must  be  fixed  in  the  pelvis,  or  be  held  firmly  at 
the  brim  by  an  assistant  in  such  a  manner  that  it  will  not  slip 
away  as  the  perforator  is  introduced. 

Operation. — The  operation  of  craniotomy  consists  of  .four 
steps : — 

(1)  The  perforation  of  the  cranium. 

(2)  The  breaking  up  and  evacuation  of  the  contents  of  the 

skull. 

(3)  The  reduction  in  size  of  the  base  of  the  skull  by  com- 

pression. 

(4)  The  extraction  of  the  foetus. 


Fig.  452. — Simpson's  Basilyst. 
A,  The  blades  for  screwing  into  base  of  skull  ;  B,  the  cephalotribe  blade. 


The  Perforation  of  the  Cranium.— The  patient  is  anaesthetised 
and  placed  in  the  dorsal  cross-bed  position,  and  the  parts  are 
thoroughly  washed  and  disinfected.  If  necessary,  preliminary 
dilatation  of  the  uterine  orifice  is  effected.  As  much  of  the 
left  hand  of  the  operator,  as  is  necessary,  is  introduced  into  the 
vagina,  and  the  head  pushed  into  a  position  of  flexion,  if  it  is 
movable  and  if  it  is  not  already  so  placed.  An  assistant  then 
from  without  holds  the  head  firmly  in  this  position,  while  the 
locked  perforator  is  cautiously  guided  through  the  vagina  under 
protection  of  the  left  hand,  until  the  point  rests  against  the  most 
dependent  part  of  the  cranial  vault,  as  shown  in  Fig.  453.  The 
lock  of  the  instrument  is  opened  and  the  blades  are  separated  by 
pressing  the  handles  together,  thus  making  two  lateral  cuts  in 
the  cranial  bones.     The  instrument  is  then  closed  and  partially 


THE  PERFORATION  OF  THE  CRANIUM  1065 

withdrawn  to  permit  of  it  being  rotated  through  ninety  degrees. 
It  is  then  again  opened,  and  a  second  cut  made  at  right  angles 
to  the  first.  In  introducing  the  instrument,  the  greatest  care 
must  be  taken  that  it  does  not  slip.  It  is  to  prevent  such  an 
accident  that  we  advise  the  introduction  of  the  perforator  through 
the  most  prominent  part  of  the  head,  whether  this  entails  its 
passage  through  a  bone  or  a  suture.  Steady  pressure  upwards 
is  also  essential,  and  all  jerking  or  sudden  movements  must  be 
avoided,  as,  if  the  instrument  was  to  slip,  most  serious  injury 
might  be  done  to  the  maternal  tissues. 


Fig.  453. — The  Performance  of  Craniotomy  :  the  Introduction  of 
the  Perforator. 

In  face  presentation,  the  perforator  can  be  most  easily  intro- 
duced through  an  orbit,  or,  if  there  is  a  difficulty  in  reaching 
it,  through  the  roof  of  the  mouth.  In  the  latter  case,  how- 
ever, the  bones  which  have  to  be  traversed  are  firmer,  and 
consequently  a  greater  degree  of  force  has  to  be  used. 

In  the  case  of  the  after-coming  head,  perforation  may  be  at 
times  very  difficult,  if  pelvic  contraction  prevents  us  from  drawing 
the  base  of  the  head  within  reach.  There  are  two  sites,  at  either 
of  which  the  perforator  can  be  introduced.  Either  the  body  of 
the  child  may  be  drawn  as  far  backwards  as  possible  and  the 
perforator  introduced  through  the  occipital  bone,  or  the  body 
may   be  drawn  forwards   and    to  one   side,   and   the    perforator 


io66 


OBSTETRICAL  OPERATIONS 


introduced  through  a  lateral  fontanelle.  The  former  method  is 
perhaps  the  easier.  An  assistant  seizes  the  child  by  the  legs 
and  draws  it  forcibly  as  far  backwards  as  possible,  while  the 
operator  introduces   the  fingers  of  his   left   hand   between   the 


Fig.  454. — The  Performance  of  Craniotomy. 

Blades  No.  1  and  2  of  Auvard's  instrument  applied  to  the  head  as  a 
cranioclast. 


occiput  and  the  back  of  the  symphysis,  and  pushes  them  up  as 
far  as  possible.  The  perforator  held  in  the  other  hand  is  then 
pushed  through  the  highest  point  of  the  bone  that  is  under  the 


THE  BREAKING  UP  AND  EVACUATION  OF  THE  BRAIN      1067 

protection  of  the  vaginal  fingers.  If  the  body  of  the  foetus  is 
of  large  size  and  fills  the  pelvic  cavity,  while  at  the  same  time 
pelvic   contraction  keeps  the   head   unusually   high,   it    may    be 


Fig.  455. — The  Performance  of  Craniotomy. 

Blade  No.  3  of  Auvard's  instrument  applied  over  the  back  of  the  head  so 
as  to  unite  with  the  others  to  make  a  cephalotribe. 

conceivably  necessary  first  to   remove  the  body  by  performing 
decapitation,  and  then  to  crush  and  extract  the  separated  head. 

The  Breaking  up  and  Evacuation  of  the  Brain. — The  second  step 
consists  in  removing  as  much  of  the  brain  as  possible.      With 


io68 


OBSTETRICAL  OPERATIONS 


this  object  the  perforator  is  pushed  up  to  the  base  of  the  skull, 
and  moved  about  freely  in  all  directions  so  as  to  break  up  the 
brain  as  completely  as  possible.      The  more  fully  this  is  done 


Fig.  456. — The  Performance  of  Craniotomy. 

Auvard's  instrument  applied,  the  handles  screwed  together,  and  the  head 

crushed. 


the  easier  will   be  the    subsequent    evacuation.      A    large-sized 
Bozemann's  catheter  is  then  introduced,  and  a  stream  of  water 


THE  EXTRACTION  OF  THE  HEAD  1069 

allowed  to  run  through  it  with  the  object  of  washing  out  the 
disintegrated  brain.  Much  time  need  not,  however,  be  spent 
over  this  part  of  the  operation,  as,  when  traction  is  applied 
to  the  head,  the  compression  of  the  latter  will  squeeze  the  brain 
out  through  the  opening  in  the  vault. 

Trie  Reduction  of  the  Skull. — If  Auvard's  combined  instrument 
is  used,  the  centre  blade,  marked  No.  1,  is  passed  upwards 
through  the  opening  in  the  cranium  and  as  deeply  as  possible 
into  the  base  of  the  skull,  taking  care  that  its  convex  surface  is 
turned  towards  the  face  of  the  foetus.  Blade  No.  2,  which  unites 
With  blade  No.  1  to  form  a  cranioclast,  is  then  applied  over  the 
face,  and  the  two  blades  tightly  screwed  together  by  means  of  the 
compression  screw  at  the  end  of  the  handles  (v.  Fig.  454).  The 
head  is  now  caught  in  a  cranioclast,  and,  if  the  disproportion 
between  it  and  the  pelvis  is  not  very  great,  a  sufficient  degree  of 
reduction  will  probably  be  obtained  by  traction.  As  the  head 
passes  through  the  pelvic  brim,  it  elongates  as  shown  in  the 
diagram  {v.  Fig.  450),  and  the  remainder  of  the  brain  is  squeezed 
out.  If,  however,  the  disproportion  is  considerable,  blade  No.  3 
must  be  applied  over  the  head  at  the  side  opposite  to  blade  No.  2, 
with  which  it  forms  a  cephalotribe  (v.  Fig.  455).  It  is  then 
locked,  and  the  two  blades  screwed  together  by  means  of  the 
compression  screw,  as  shown  in  Fig.  456.  If  the  blades  have 
been  so  applied  that  they  include  the  base  of  the  skull  in  their 
grip,  a  marked  degree  of  reduction  is  obtained.  If  one  applica- 
tion of  the  cephalotribe  does  not  sufficiently  reduce  the  size  of 
the  head,  the  instrument  should  be  taken  off  and  re-applied  to 
the  head  in  a  diameter  at  right  angles  to  its  former  position. 

Simpson's  basilyst  also  consists  of  three  blades,  two  of  which 
interlock  to  form  an  instrument  with  a  screw-ended  tip,  while  the 
third  can  be  applied  outside  the  head  to  form  with  the  others  a 
cranioclast.  The  first  two  blades  interlocked  are  introduced  into 
the  cranial  cavity  and  screwed  into  the  base  of  the  skull.  Then 
the  handles  are  compressed  and  the  blades  separated,  with  the 
result  that  the  bones  of  the  base  are  split  apart.  If  necessary, 
the  instrument  is  then  rotated  through  a  right  angle  and  the 
blades  again  separated.  So  great  a  breaking  up  of  the  base  of 
the  skull  results  from  this,  that,  if  the  disproportion  between  the 
head  and  the  pelvis  is  not  very  great,  the  head  can  be  pushed 
down  through  the  pelvis  by  pressure  applied  from  without.  If 
this  cannot  be  done,  the  third  blade  is  applied  outside  the  skull 
and  the  head  extracted  as  with  a  cranioclast. 

Extraction. — In  consequence  of  the  crushing  force  being  applied 
to  one  diameter,  there  is  always  a  tendency  to  a  compensatory 
increase  in  the  opposite  diameter,  and  consequently  it  is  advisable 
to  rotate  the  head  during  extraction  by  means  of  the  cranioclast 
in  such  a  manner  that  its  greatest  diameters  correspond  to  the 
greatest  diameters  of  the  pelvis.  Traction  must  be  applied  in 
the  axis  of  the  pelvic  canal,  and,  during  the  descent  of  the  head, 


1070  OBSTETRICAL  OPERATIONS 

repeated  examination  must  be  made  with  the  fingers  in  the 
vagina  to  ascertain  that  pieces  of  broken  bone  are  not  protruding 
through  the  cranial  skin,  as  severe  laceration  of  the  maternal 
soft  parts  can  be  brought  about  by  such  pieces. 

It  was  formerly  not  infrequently  taught  that,  after  perforation 
and  crushing,  it  was  advisable  to  leave  the  expulsion  of  the  head 
to  the  natural  efforts.  Such  a  course  is,  however,  now  seldom  or 
never  recommended,  and  is  quite  opposed  to  the  principles  that 
govern  modern  obstetrical  practice.  Everything  points  to  the  ad- 
visability of  delivering  the  woman.  She  is  already  anaesthetised, 
she  has  probably  been  for  a  considerable  time  in  labour  and 
requires  to  be  delivered,  and  the  retention  of  the  dead  foetus 
in  the  uterine  cavity  favours  the  occurrence  of  saprophytic 
infection. 

Prognosis. — There  should  be  no  maternal  mortality  associated 
with  craniotomy,  if  the  operation  is  performed  in  time  and  is  not 
attempted  in  the  case  of  absolute  pelvic  contraction.  As, 
however,  the  operation  is  as  a  rule  postponed  until  the  last 
moment,  in  order  to  give  the  infant  every  chance  of  being 
expelled  spontaneously,  it  may  happen  that  it  is  performed  in 
the  case  of  patients  who  are  seriously  collapsed,  or  who  have 
been  infected  by  previous  manipulations.  There  is  no  excuse  for 
such  a  postponement  when  the  infant  is  dead,  and  the  opera- 
tion should  be  performed  as  soon  as  it  is  plain  that,  without  it, 
delivery  cannot  be  effected  per  vaginam.  There  is  always  some 
risk  of  laceration  of  the  maternal  soft  parts  by  pieces  of  projecting 
bone,  and  this  must  be  guarded  against,  by  carefully  noting  the 
effect  of  traction  on  the  cranial  bones,  and  by  removing  any 
pieces  which  protrude  through  the  cranial  skin. 


EMBRYOTOMY 

The  term  embryotomy  strictly  means  any  cutting  operation 
performed  on  the  foetus,  but,  in  practice,  it  has  come  to  mean 
any  cutting  operation  performed  on  the  body  of  the  foetus  with  the 
object  of  reducing  its  size  or  altering  its  shape.  Three  different 
operations  are  included  in  the  term  : — Decapitation,  evisceration, 
and  cleidotomy. 

Decapitation.- — -By  decapitation  is  meant  the  separation  of  the 
head  of  the  foetus  from  its  body  by  cutting  or  tearing  through  the 
neck. 

Indications. — The  operation  of  decapitation  is  seldom  required  in 
obstetrical  practice.  Its  chief  indication  is  neglected  shoulder 
presentation  in  which  version  cannot  be  performed,  and  in  which 
the  neck  can  be  reached,  and  such  cases,  as  the  name  implies, 
only  occur  when  the  patient  has  been  neglected  during  labour. 
Decapitation  is  also  indicated  in   cases  of   locked   twins,  when 


DECAPITATION  107 1 

the  after-coming  head  of  the  first  has  become  interlocked  with 
the  forecoming  head  of  the  second,  and  their  disengagement  is 
impossible. 

Instruments. — In  neglected  shoulder  presentation,  the  only 
special  instrument  that  is  required  is  some  form  of  decapitator. 
Many  different  forms  of  instrument  have  been  invented  since 
Ramsbotham*  devised  his  sharp  sickle-shaped  hook.    The  instru- 


!/3  Scale 


Fig.  457. — Braun's  Blunt  Hook  for  Decapitation. 

ment  most  generally  used  at  the  present  time  is  the  blunt  hook 
devised  by  Braun,  and,  though  it  may  not  sever  the  neck  with 
the  same  rapidity  as  a  sharp  hook,  it  is  a  safer  instrument 
and  most  efficient.  For  decapitation  of  the  after-coming  head, 
all  that  is  required  is  a  pair  of  strong  scissors. 

Operation. — The  patient  is  anaesthetised  and  placed  in  the 
dorsal  cross-bed  position.  The  presenting  shoulder  is  drawn 
down  as  far  as  possible  by  traction  on  the  prolapsed  arm.     The 


Fig.  458. — Galabin's  Modification  of  Ramsbotham's  Decapitating  Hook. 

fingers  of  the  hand  corresponding  to  the  side  at  which  the 
head  lies  are  introduced  into  the  vagina,  and  passed  upwards  in 
such  a  manner  as  to  encircle  the  neck  from  behind,  the  thumb 
encircling  it  from  in  front.  The  hook  is  then  guided  upwards 
through  the  vagina  along  the  palm  of  the  hand,  and  insinuated 
along  the  anterior  surface  of  the  neck  under  cover  of  the  thumb, 
as  shown  in  Fig.  459,  until  the  point  is  above  the  neck,  when  it  is 
turned  inwards  and  drawn  forcibly  downwards  over  the  neck  in 
such  a  manner  that  it  includes  the  spinal  column  in  its  crook. 
The  hook  is  then  forcibly  rotated  so  as  to  fracture  the  spinal 
column.  The  soft  parts  can  be  severed  either  by  twisting  them 
away  with  the  hook  or  by  dividing  them  with  blunt-pointed 
scissors.     The  head  is  next  pushed  up  out  of  the  way,  and  the 

*  '  The  Principles  and  Practice  of  Obstetric  Medicine  and  Surgery,' 2nd  ed., 
P-  359- 


1072 


OBSTETRICAL  OPERATIONS 


prolapsed  arm  is  drawn  further  down  so  as  to  bring  the  other 
arm  within  reach.     This  is  in  turn  pulled  down,  and  the  trunk 


Fig.  459.  — Decapitation  with  Braun's  Blunt  Hook  in  a  Neglected 
Shoulder  Presentation. 

extracted  by  traction  on  both  arms.  If  the  pelvis  is  contracted, 
and  the  size  of  the  body  renders  its  delivery  difficult,  the  body 
may  be  reduced  by  performing  evisceration. 


EVISCERATION  1073 

Galabin,  who  is  an  ardent  believer  in  his  modification  of  Rams- 
botham's  hook,  recommends  that  the  operation  of  decapitation  be 
performed  as  follows  : — '  Bring  the  shoulder  as  low  as  possible  by- 
traction  upon  the  prolapsed  arm.  The  neck  can  be  then  generally 
reached  by  the  left  hand  passed  into  the  vagina.  Carry  the 
decapitator,  protected  by  the  flexor  surface  of  the  fingers,  up  in 
front  of  the  neck,  passing  it  along  the  arm,  the  point  directed 
toward  the  head,  until  it  reaches  the  level  of  the  neck.  Now, 
draw  the  decapitator  firmly  downwards  at  the  same  time  that  its 
handle  is  swayed  backward  and  forward  as  widely  as  the  vaginal 
outlet  will  allow.     In  this  way,  the  neck  is  quickly  cut  through.' 

The  extraction  of  the  severed  head  is  the  last  step,  and  in  some 
cases  may  give  rise  to  difficulty.  If  there  is  no  contraction  of 
the  pelvis,  the  easiest  method  of  extraction  consists  in  pressing 
the  head  down  into  the  pelvic  brim  with  the  hand  on  the  abdomen, 
and  in  then  introducing  the  other  hand  into  the  uterus,  and 
grasping  the  head  with  two  fingers  in  the  mouth.  The  head  is 
then  delivered  as  in  the  case  of  an  after-coming  head  by  traction 
on  the  mouth  assisted  by  firm  pressure  from  without.  If  this 
does  not  succeed,  one  blade  of  the  cranioclast  may  be  introduced 
into  the  mouth  as  recommended  by  Winckel,  the  other  blade 
being  placed  over  the  divided  tissues  of  the  neck,  and  traction 
thus  applied.  If  the  pelvis  is  contracted,  and  delivery  of  the  un- 
reduced head  is  impossible,  the  latter  must  be  perforated  and 
crushed  in  the  ordinary  manner. 

Evisceration. — Evisceration  is  the  term  applied  to  the  removal 
of  one  or  more  of  the  abdominal  or  thoracic  viscera,  with  the 
object  of  reducing  the  size  of  the  foetal  trunk. 

Indications. — Evisceration  is  indicated  in  longitudinal  lies  of  the 
foetus  if  the  size  of  the  foetal  body  obstructs  delivery  after  the 
birth  of  the  head  or  breech.  It  is  also  indicated  in  neglected 
shoulder  presentations  in  which  the  neck  cannot  be  reached  and 
decapitation  performed. 

Instruments. — The  only  special  instrument  required  is  one  with 
which  to  make  an  opening  into  the  trunk  of  sufficient  size  to 
admit  the  fingers.  For  this  purpose  Simpson's  perforator,  or  a 
pair  of  strong,  long-handled,  and  sharp-pointed  scissors,  answers 
well. 

Operation. — The  patient  is  placed  in  the  dorsal  cross-bed  position 
and  anaesthetised.  The  hand  is  passed  into  the  vagina  at  which- 
ever side  there  is  most  room,  and  the  perforator,  guided  up  along 
it,  is  pushed  into  the  most  accessible  part  of  the  thoracic  or 
abdominal  cavity.  The  fingers  are  then  introduced  through  the 
hole  thus  made  and  the  nearest  viscus  is  caught  and  pulled  away. 
If  the  opening  in  the  foetal  body  is  not  of  sufficient  size  to  permit 
this  to  be  done,  it  must  be  enlarged  with  scissors.  In  this  way, 
the  liver,  lungs,  and  heart  can  be  removed.  As  soon  as  the  size 
of  the  trunk  is  sufficiently  reduced,  the  body  can  be  delivered. 

68 


1074  OBSTETRICAL  OPERATIONS 

In  the  case  of  a  neglected  shoulder  presentation,  this  can  be  best 
done  by  fracturing  the  spinal  column  with  a  Braun's  hook,  or  by- 
cutting  it  through  with  a  stout  scissors.  The  lower  half  of  the 
body  is  then  pulled  down  and  the  foetus  extracted  by  a  mechanism 
similar  to  that  which  occurs  in  spontaneous  evolution.  If  the 
spinal  column  cannot  be  fractured,  pass  the  hand  upwards  into 
the  uterus,  seize  the  feet,  and  extract  the  child  as  a  breech 
presentation. 

Cleidotomy. — Cleidotomy  is  the  term  applied  to  the  operation 
of  division  of  the  clavicles  of  the  foetus  with  the  object  of 
reducing  the  width  of  the  shoulders  and  of  making  them  more 
readily  adaptable  to  the  pelvic  canal.  Bonnaire*  has  shown  by 
experiments  on  dead  children  that  unilateral  cleidotomy  reduced 
the  bis-acromial  circumference  by  from  one  to  three  centimetres, 
bi-lateral  cleidotomy  by  from  three  to  four  centimetres.  The 
statement  made  by  Bonnaire  that  in  no  case  on  which  he  experi- 
mented was  the  subclavian  artery  injured  or  the  subclavius 
muscle  divided  is  supported  by  the  results  of  Ballantyne's 
experiments.!  It  is  possible  therefore  that  the  operation  can 
be  performed  in  cases  of  necessity  on  the  living  foetus  without 
causing  its  death. 

Indications. — Cleidotomy  is  indicated  when  the  shoulders  are 
impacted  in  the  pelvis  in  consequence  of  their  large  size,  of 
their  failure  to  rotate,  or  of  pelvic  contraction,  if  it  is  impossible 
to  deliver  the  foetus  by  other  means,  even  after  the  arms  have 
been  brought  down.  So  far  as  we  know,  the  operation  has  been 
performed  only  on  the  dead  foetus,  either  as  an  accessory  to,  or 
without,  a  preliminary  craniotomy. 

Instrument. — The  only  special  instrument  required  is  a  pair  of 
strong  scissors  with  long  handles. 

Operation. — The  necessity  for  the  operation  will  usually  arise 
more  or  less  unexpectedly  during  delivery,  owing  to  the  impos- 
sibility of  delivering  the  shoulders  after  the  birth  of  the  head.  In 
such  cases,  every  effort  must  be  made  to  deliver  the  infant  in  the 
manner  which  has  been  already  described  when  discussing  the 
treatment  of  impacted  shoulders,  and,  if  such  efforts  fail,  the 
patient  should  be  rapidly  drawn  into  the  cross-bed  position,  and 
cleidotomy  performed.  In  performing  the  operation,  two  fingers 
are  slipped  into  the  vagina  along  the  anterior  aspect  of  the  child, 
until  the  prominent  ridge  formed  by  the  clavicle  is  felt.  The 
scissors  is  then  guided  upwards  under  cover  of  these  fingers  until 
it  comes  to  the  clavicle,  when  it  is  gently  and  carefully  opened 
just  wide  enough  to  admit  the  bone,  and  the  latter  is  divided  at 
or  near  its  middle.  As  soon  as  division  is  complete,  the  bones 
will  override  one    another.     If  there  is  any  possibility  that  the 

*  '  De  la  reduction  des  epaules  dans  1'accouchement  dystocque,'  Presse 
Medicale,  No.  21,  p.  125,  Mars  14,  1900. 

f  '  Cleidotomy,'  Trans.  Edinburgh  Obstet.  Sue,  vol.  xxvi.fp.  24. 


CLEWOTOMY  1075 

foetus  is  alive,  care  must  be  taken  to  divide  the  bone  alone,  and 
not  to  injure  the  structures  lying  under  it.  Attempts  to  deliver 
the  fcetus  may  be  then  repeated,  but  if  they  are  unsuccessful  the 
opposite  clavicle  must  be  divided  in  a  similar  manner. 

We  have  recently  had  to  perform  cleidotomy  in  the  case  of  a 
large  infant,  whose  shoulders  were  arrested  on  account  of  their 
size.  The  right  shoulder  remained  above  the  brim,  and  the  left 
shoulder  descended  into  the  cavity.  Traction  had  failed  to  deliver, 
the  arms  could  not  be  brought  down,  and  the  fcetus  was  dead. 
Both  clavicles  were  divided  with  scissors,  and  traction  again 
made  without  result.  The  skin  over,  and  the  posterior  muscular 
attachments  of,  the  right  scapula  were  then  divided  with  scissors, 
and  the  scapula  and  shoulder  thus  enabled  to  move  round 
towards  the  front  of  the  chest.  Delivery  was  then  easily  effected 
by  traction.  The  infant  weighed  ten  pounds.  The  bis-acromial 
circumference,  when  the  shoulders  were  placed  in  their  normal 
position,  measured  forty-five  centimetres  ;*  when  the  circum- 
ference was  compressed,  the  division  of  the  clavicles  and  of  the 
scapular  muscles  enabled  it  to  be  reduced  to  thirty-three  centi- 
metres. The  value  of  the  division  of  the  scapular  muscles  in 
enabling  a  further  reduction  in  the  shoulder-girdle  after  cleido- 
tomy is  shown  by  this  case  to  be  considerable. 

It  is  interesting  to  note  that,  in  this  case,  the  sub-clavicular 
vessels  were  not  injured  during  the  division  of  the  clavicles, 
though  the  vessels  on  the  right  side  were  divided  during  the  sub- 
sequent procedure.  In  performing  cleidotomy,  if  there  is  any 
chance  that  the  infant  may  be  still  alive,  it  is  important  to  make 
the  division  as  near  the  scapular  end  of  the  bone  as  possible,  as 
the  farther  out  it  is  made  the  greater  the  distance  between  the 
vessels  and  the  clavicle,  and  hence  the  less  risk  there  is  of  injuring 
the  former. 

*  The  bis-acromial  circumference  normally  measures  thirty-four  centi- 
metres. 


68- 


PART   X 
THE    INFANT 


CHAPTER  I 

THE  PHYSIOLOGY  AND  CARE  OF  THE  INFANT 
—INFANT  FEEDING 

The  Management  of  the  Infant  after  Birth,  Ligation  of  the  Cord,  Dressing 
of  the  Umbilical  Wound — Temperature,  Pulse  and  Respiratory  Rate  of 
Infant — Urine — Meconium — Weight.  Infant  Feeding — Breast  Feeding, 
Composition  of  Cow's  and  Human  Milk — The  Wet-nurse — Artificial 
Feeding,  Proprietary  Foods,  Cow's  Milk- — General  Remarks  on  Infant 
Feeding. 


THE  PHYSIOLOGY  AND  CARE  OF  THE  INFANT 

We  must  now  return  to  the  commencement  of  the  third  stage 
of  labour  for  the  purpose  of  describing  the  management  of  the 
infant  after  birth.  Immediately  the  infant  is  born,  the  nurse 
should  wipe  its  eyes  with  a  soft  linen  cloth  in  order  to  remove 
any  material  which  may  have  found  its  way  into  them  during  the 
passage  of  the  head  through  the  vagina,  and  the  mouth  is 
similarly  treated  if  it  contains  mucus.  Usually,  the  infant  then 
cries,  if  it  has  not  already  done  so,  and  commences  to  breathe 
naturally.  If  it  does  not  do  so,  the  finger  should  be  passed  into 
the  mouth  and  any  mucus  which  may  be  far  back  gently  hooked 
out.  This  procedure  is  greatly  facilitated  by  suspending  the 
child  by  the  feet,  as  this  enables  the  mucus  to  run  out  of  the 
larynx.  As  soon  as  all  mucus  has  been  removed,  attempts  must 
be  made  to  make  the  infant  inspire,  if  it  has  not  already  done  so. 
Usually,  some  slight  cutaneous  stimulation  is  all  that  is  necessary, 
such  as  a  dash  of  cold  water  or  a  gentle  slap  with  the  hand.  If 
this  is  not  sufficient  there  must  be  some  pathological  condition 
present,  which  will  be  considered  under  the  head  of  asphyxia 
neonatorum.  As  soon  as  the  infant  is  breathing  strongly,  it  is 
laid  between  the  mother's  thighs,  a  little  way  from  the  vulva,  and 
in  such  a  position  that  it  will  not  be  pressed  upon  by  the  mother 
and  that  there  is  no  tension  on  the  cord. 

The  next  step  consists  in  the  ligation  of  the  cord.  The  old 
dispute  as  to  when  the  cord  should  be  tied  possesses  now  little 
more  than  an  academic  interest,  as  it  is  conclusively  settled  that 
this  should  not  be  done  until  all  pulsations  in  the  cord   have 

1079 


1080  THE  INFANT 

ceased.  Formerly,  it  was  customary  to  tie  the  cord  the  moment 
the  foetus  was  born,  or  as  soon  as  it  had  cried  lustily,  and  in  spite 
of  the  representations  of  White  of  Manchester,  this  practice  con- 
tinued up  to  comparatively  recent  times.  White,  who  was  perhaps 
the  most  scientific  obstetrician  of  his  day,  clearly  recognised  the 
absurdity  of  supposing  that  it  was  possible  for  the  change  from  the 
placental  to  the  pulmonary  circulation,  with  all  that  this  implies, 
to  take  place  in  a  moment.  '  Is  it  possible,'  he  writes,  '  that  this 
wonderful  alteration  in  the  human  machine  should  be  properly 
brought  about  in  one  instant  of  time,  and  at  the  will  of  a  by- 
stander ?  .  .  .  By  this  rash  and  inconsiderate  method  of  tying 
the  navel  string  before  the  circulation  in  it  is  stopped,  I  doubt 
not  but  many  children  have  been  lost.'*  The  experiments  of 
Budin  and  of  Ribemont-Dessaignes  have  set  the  question  at  rest. 
Budini  has  proved  that  an  infant,  in  whom  the  pulsations  of 
the  cord  are  allowed  to  cease  before  ligation,  gains  on  an  average 
92  grammes  (3  oz.)  of  blood,  which  it  would  have  otherwise  lost, 
a  loss  which  would  be  equivalent  to  one  of  sixty  ounces  in  the 
adult.  It  is  possible  that  this  extra  blood  may  find  its  way  into 
the  foetal  circulation  in  one  of  two  ways.  First,  it  may  be 
sucked  in  from  the  placenta — thoracic  aspiration — as  a  result  of 
a  negative  pressure  in  the  great  vessels  near  the  heart  owing  to 
the  establishment  of  the  pulmonary  circulation  and  the  demand 
for  additional  blood ;  or,  secondly,  it  may  be  forced  into  the 
foetal  vessels  owing  to  the  contraction  of  the  uterus  upon  the 
placenta  (Schucking  and  Porak).  In  the  first  event,  it  would 
be  clearly  advisable  to  permit  the  influx  of  blood  to  occur  ;  in 
the  second  event,  it  would  probably  be  inadvisable  to  do  so. 
Ribemont-Dessaignes!  has,  however,  shown,  by  observations  on 
the  blood-pressure  of  the  umbilical  arteries  and  vein  in  cases  of 
immediate  and  late  ligation,  that  the  influx  of  blood  is  due  to 
thoracic  aspiration.  The  suggestion  that  jaundice  is  more 
common  in  the  case  of  late  ligation  of  the  cord  has  been  disposed 
of  by  Schmidt,§  as  his  observations  showed  that  72  per  cent,  of 
children  in  whom  immediate  ligation  was  adopted  were  jaundiced, 
while  only  42  per  cent,  were  jaundiced  when  the  cord  was  not 
tied  until  ten  minutes  after  birth.  The  occurrence  of  jaundice  is 
not  in  itself  a  matter  of  very  great  importance,  as,  in  its  common 
form,  it  is  probably  due  to  the  breaking  down  of  blood  corpuscles, 
and  not  to  absorption  of  bile.  An  additional  argument  in  favour 
of  late  ligation,  if  one  is  required,  is  the  fact  that  infants  in  whom 
this  course  is  adopted  are  stronger,  and  gain  more  rapidly  in 
weight. 

*  '  A  Treatise  on  the  Management  of  Pregnant  and  Lying-in  Women,'  etc., 
third  edition,  p.  109  et  seq.     London,  1785. 

j  '  A  quel  Moment  doit-on  operer  la  Ligature  du  Cordon  ombilicale  ?'  Pro- 
gri-s  MM.,  1876. 

J  Arch,  de  Tocol.,  October,  1879. 

§  Archiv  f.  Gyn.,  vol.  xlv.,  1894. 


THE  MANAGEMENT  OF  THE  UMBILICAL  CORD  1081 

The  question,  When  is  the  cord  to  be  tied  ?  being  thus  answered, 
we  must  now  discuss  the  equally  important  question,  How  is  it  to 
be  tied  and  divided  ? 

The  difference  in  the  opinions  held  regarding  the  proper 
method  of  treating  the  cord  after  the  birth  of  the  infant  is 
perhaps  one  of  the  most  surprising  things  in  modern  obstetrics, 
especially  when  one  considers  the  apparent  simplicity  of  the  ques- 
tion, and  the  ease  with  which  its  answer  can  be  experimentally 
determined.  In  spite  of  this,  at  the  present  time  there  are 
advocates  of  the  use  of  the  ligature  and  of  the  use  of  no  ligature ; 
of  division  with  the  scissors ;  of  amputation  round  the  skin 
edge ;  of  the  application  of  clamps,  and  of  division  with  the 
thermo-cautery  ;  of  dry  dressings,  of  wet  dressings,  and  of  no 
dressings.  In  spite  of  all  these  numerous  practices,  or,  perhaps 
it  would  be  more  correct  to  say,  in  consequence  of  them,  the 
essential  details  of  the  treatment  of  the  cord  are  apt  to  be  over- 
looked. To  constitute  a  suitable  method  of  treatment,  two 
conditions  must  be  fulfilled  :  — 

(1)  It  must  be  a  simple  method,  capable  of  being  carried  out  by 
any  reasonably  skilled  person,  and  under  any  circumstances. 

(2)  It  must  preserve  the  initial  asepsis  of  the  cord. 

The  first  condition  will  at  once  sweep  out  of  the  field  all  such 
proposals  as  that  of  primary  amputation  of  the  cord  proposed  by 
Dickinson.*  This  may  furnish  admirable  results  in  cases  in 
which  it  can  be  properly  performed,  and  at  the  same  time  may 
be  simple  in  its  technique  ;  but  it  is  not  suitable  for  use  in  the 
majority  of  cases,  and  hence  there  does  not  appear  to  be  any 
particular  object  to  be  gained  by  its  use  in  a  small  proportion  of 
cases.  For  similar  reasons,  the  use  of  clamps  (Barf)  or  of  the 
thermo-cautery  is  not  desirable.  The  abolition  of  the  ligature  is 
also  contra-indicated,  in  that  though  in  many  cases  it  is  not 
necessary,  in  others  it  is  necessary,  and  the  great  majority  of 
persons  who  conduct  labours  will  never  be  sufficiently  skilled  to 
be  able  to  distinguish  the  cases  in  which  ligation  is  required 
from  those  in  which  it  is  not.  It  is  true  that  Kellar  j  has  recorded 
2,000  cases  of  non-ligation  with  good  results,  but,  even  so,  the 
practice  cannot  be  recommended  for  general  adoption. 

The  second  condition  can  be  fulfilled  in  a  number  of  ways,  but 
it  is  necessary  to  select  one  which  will  also  fulfil  the  first  con- 
dition. Perhaps,  the  easiest  and  safest  method  to  adopt  is  one 
which  will  prevent  any  non-aseptic  material  or  instrument  from 
coming  into  contact  with  the  cord,  and  which  will  keep  the  latter 
dry,  and  so  encourage  the  desiccation  of  the  stump 

A  method  which  fulfils  both  these  conditions,  so  long  as 
due  attention  is   paid  to  asepsis,  is  the  well-known  practice  of 

*  '  Complete  Amputation  of  the  Umbilical  Cord,'  Trans,  of  the  American 
Gyncecol.  Soc,  1899,  p.  267. 

t   '  Peau  de  Cerf.,'  Revue  Intern,  de  Med.  et  de  Chir.,  1897,  No.  16. 

J   '  Non-ligation  of  the  Umbilical  Cord,'  Pacific  Med.Joum.,  January,  1897. 


1082  THE  INFANT 

tying  the  cord  with  stout  linen  thread  and  dividing  it  with 
scissors.  The  ligature  with  which  the  cord  is  tied  and  the 
scissors  with  which  it  is  divided  should  be  as  sterile  as  are  the 
ligatures  and  instruments  for  use  in  any  surgical  procedure. 
The  same  remark  applies  also  to  the  dressings  which  are  subse- 
quently applied.  The  cord  is  tied  in  two  places,  one  ligature 
being  placed  two  inches  from  the  umbilicus  of  the  child,  and  the 
other  as  close  as  possible  to  the  vulva  of  the  mother.  The 
object  of  the  second  ligature  will  be  subsequently  explained.  The 
cord  is  then  divided  half  an  inch  above  the  first  ligature,  a  pad 
of  dry  sterilised  cotton-wool  is  applied  to  the  umbilicus,  and  the 
remainder  of  the  dressing  postponed  until  the  infant  has  been 
washed.  Linen  thread  doubled  and  with  knotted  ends  is  generally 
used  for  the  ligature.  It  should  be  boiled  before  use,  or  else 
allowed  to  lie  in  corrosive  sublimate  solution  (i  in  500)  for  several 
hours. 

If  the  cord  is  very  '  fat ' — i.e.,  if  there  is  a  large  amount  of 
Whartonian  jelly,  it  is  sometimes  difficult  to  tie  the  ligature 
sufficiently  tightly  to  prevent  oozing  from  the  cut  surface.  In 
such  cases,  Budin*  recommends  that  the  ligature  be  about 
twelve  inches  in  length.  The  cord  is  first  tied  circularly  as  before, 
and  cut  off  one  centimetre  above  the  ligature.  The  ends  of  the 
latter  are  then  brought  over  the  face  of  the  cut  surface,  and  tied 
again  in  such  a  manner  that  they  lie  at  right  angles  to  the  first 
loop,  and  that  they  divide  the  portion  of  cord  beyond  the  first 
ligature  into  two  parts,  in  one  of  which  is  the  vein  and  an  artery, 
in  the  other  the  second  artery.  Finally,  each  of  these  parts  is 
tied  separately  with  the  ends  of  the  same  ligature. 

It  sometimes  happens  that  the  cord  is  very  soft,  and  that 
a  ligature  made  of  linen  thread  cuts  through  it.  In  such  cases, 
some  softer  and  thicker  material  must  be  used  as  a  substitute  for 
thread,  such  as  a  piece  of  circular  lampwick,  similar  to  what 
is  used  for  drainage  purposes,  and  of  about  the  thickness  of  a 
goose-quill. 

The  object  of  the  second  ligature  in  the  majority  of  cases  is 
merely  to  serve  as  an  index  upon  the  cord  by  means  of  which  we 
can  watch  the  elongation  of  the  portion  which  lies  outside  the 
vulva,  and  so  determine  whether  the  placenta  has  descended  into 
the  vagina  or  not.  In  cases  of  twins,  it  is  also  required  in  order 
to  check  haemorrhage  from  the  placental  end  of  the  cord,  a  com- 
plication which  might  otherwise  occur  in  consequence  of  an 
anastomosis  between  the  circulation  of  the  infants. 

As  soon  as  the  mother  has  been  comfortably  settled,  the  toilet 
of  the  infant  must  be  performed.  This  should  be  preceded  by 
a  careful  examination,  to  ascertain  that  neither  defects  nor  de- 
formities are  present,  nor  injuries  which  have  occurred  during 
delivery.     The  urethra  and  the  anus  must  be  specially  examined 

*  'Ligature  du  Cordon,  nouveau  Procede,'  Congres  de  Bordeaux,  August, 
l895-  P-  5°°- 


THE  MANAGEMENT  OF  THE   UMBILICAL  CORD  1083 

to  note  that  they  are  patulous.  The  infant  is  then  washed  care- 
fully by  the  nurse  in  the  ordinary  manner.  If  there  is  an  unusual 
amount  of  vernix  caseosa,  it  is  well  to  first  rub  the  infant  over 
with  a  little  olive-oil  or  vaseline,  and  then  to  wash  this  off  with 
soap  and  water.  The  eyes  must  be  carefully  cleansed  for  the 
second  time,  and  all  concretions  in  the  canthus  washed  away.  In 
all  cases  in  which  there  is  any  inflammatory  condition  of  the 
vagina  of  the  mother,  whether  there  is  a  definite  history  of 
gonorrhoea  or  not,  Crede's  prophylactic  treatment  of  ophthalmia 
neonatorum  must  be  adopted."  This  consists  in  dropping  into 
each  eye  one  drop  of  a  two  per  cent,  solution  of  nitrate  of  silver. 
A  one  per  cent,  solution  has  been  found  to  answer  the  same 
purpose  in  the  wards  of  the  Rotunda  Hospital.  Of  late,  a 
twenty  per  cent,  solution  of  argyrol  has  been  recommended  instead 
of  nitrate  of  silver.  It  is  less  irritating  and'  apparently  just  as 
efficacious,  and  so  in  our  opinion  is  preferable.  In  institutions, 
prophylactic  measures  should  be  adopted  as  a  routine  practice. 

As  soon  as  the  infant  is  washed,  the  cord  is  carefully  dried,  and 
then  dusted  over  with  an  antiseptic  powder,  such  as  equal  parts 
of  boracic  acid  and  starch,  or  bismuth  and  starch,  and  covered 
with  sterilised  cotton- wool,  if  such  can  be  obtained,  or  with  wool 
impregnated  with  a  mild  antiseptic.  This  dressing  is  removed 
night  and  morning,  the  cord  powdered,  and  a  fresh  pad  applied. 
On  account  of  the  great  importance  of  keeping  the  cord  dry, 
many  writers  recommend  not  to  bath  the  infant  until  the  cord  has 
separated  and  the  navel  healed.  This  is  a  point  which  is  worthy 
of  more  attention  than  it  usually  receives.  Bastard,)  writing  in 
1897,  stated  that  in  the  case  of  two  sets  of  infants,  to  one  of 
whom  a  daily  bath  was  given  and  to  the  other  only  one  bath  at 
birth,  the  cord  separated  in  the  unwashed  infants  on  an  average 
after  5*4  days,  while  in  those  that  were  washed  it  took  an  average 
of  7*4  days.  Further,  pathological  disturbances,  such  as  erythema 
and  suppuration  of  the  stump,  occurred  in  the  washed  infants  in 
19  per  cent,  of  cases,  in  the  unwashed  infants  in  6*3  per  cent. 
These  figures  are  striking,  and  in  view  of  the  fact  that  the 
necessary  cleanliness  can  be  maintained  by  sponging  over  the 
infant  without  allowing  the  umbilicus  to  get  wet,  it  would  seem 
to  be  advisable  to  omit  the  bath  until  the  navel  has  healed. 
Pinard  has  followed  such  a  course  since  1891  (Dickinson )4 

If  the  primary  asepsis  of  the  cord  has  been  preserved,  the  latter 
will  gradually  dry  up  and  mummify,  and  separate  between  the 
fourth  and  the  seventh  day.  The  umbilical  arteries  then  gradually 
shorten,  and  the  stump  of  the  cord  is  drawn  into  the  umbilicus, 
which  it  fills,  so  preventing  the  occurrence  of  an  umbilical  hernia. 

*  '  Die  Verhutung  der  Augenentziindung  beim  Neugeborenden,'  Berlin, 
1884. 

t  '  Contribution  a  1' Etude  du  Traitement  du  Cordon  ombilicale,  etc.,  Action 
des  Bains  '  (These  de  Paris,  Steinheil,  1S97). 

X  Op.  tit.,  p.  306. 


1084  THE  INFANT 

The  usual  temperature  of  a  newly-born  infant  is  about  99*8°  F. 
This  temperature  falls  a  little  after  the  first  bath,  and  then  ranges 
between  98-8°  and  990  F.  A  temperature  of  more  than  ioo°  F. 
must  always  be  considered  to  be  pathological.  The  easiest 
method  of  taking  the  temperature  of  an  infant  consists  in  passing 
the  bulb  of  the  thermometer  into  the  rectum.  When  the  infant 
is  awake,  the  rate  of  respiration  varies  even  in  perfect  health 
between  the  rather  wide  limits  of  thirty  and  sixty  per  minute. 
During  sleep,  the  rate  is  more  regular,  and  is  slightly  more 
frequent.  The  pulse-rate  is  also  somewhat  irregular,  and  is 
easily  increased  by  any  excitement  such  as  crying,  or  while 
suckling.  Its  correct  rate  can  be  best  determined  when  the  infant 
is  asleep,  either  by  feeling  the  pulse  at  the  wrist  or  over  the 
heart,  or  by  counting  the  pulsations  of  the  anterior  fontanelle. 
The  average  pulse-rate  during  the  first  two  months  is  137  per 
minute,  from  the  second  to  the  sixth  month  128  per  minute,  and 
from  the  sixth  to  the  twelfth  month  120  per  minute. 

The  urine  of  the  newly-born  infant  is  slightly  acid,  of  a  pale 
yellow  colour,  and  of  a  specific  gravity  of  1005  to  1007.  It  is 
passed  from  six  to  fifteen  or  twenty  times  daily.  During  the  first 
two  or  three  days  after  birth,  the  daily  amount  varies  between 
three  and  twelve  drachms,  and  this  gradually  increases  until  by 
the  sixteenth  or  seventeenth  day,  it  amounts  to  between  fifty-seven 
and  eighty-five  drachms. 

Retention  of  urine  occasionally  occurs  during  the  first  twenty- 
four  hours  after  birth,  and  on  this  account  it  is  always  the  duty  of 
the  medical  attendant  to  inquire  at  his  first  visit  if  the  baby  has 
passed  water.  The  usual  cause  of  retention  is  the  blockage  of 
the  orifice  of  the  urethra  by  a  small  plug  of  vernix  caseosa,  which 
in  the  male  infant  may  be  found  beneath  the  prepuce,  in  the 
female  infant  between  the  labia.  Occasionally,  the  cause  of  the 
retention  may  be  more  serious,  and  be  found  in  some  congenital 
obstruction  to  the  passage  of  urine,  such  as  an  imperforate 
urethra.  If  an  unduly  large  amount  of  urine  is  allowed  to 
accumulate  in  the  bladder,  the  latter  can  be  felt  as  a  tense  tumour 
reaching  as  high  as  the  umbilicus.  In  such  cases,  a  condition  of 
paresis  of  the  bladder  wall  sets  in,  and  the  infant  is  unable  to 
empty  the  bladder  even  after  the  obstruction  has  been  removed. 
If  the  infant  does  not  pass  water  within  a  couple  of  hours  of  its 
birth,  the  orifice  of  the  urethra  must  be  examined,  and  any  collec- 
tion of  vernix  removed.  If  the  infant  still  does  not  pass  water 
apply  a  warm  stupe  to  the  lower  part  of  the  abdomen,  and,  if  this 
fails,  place  the  infant  in  a  hot  bath,  and  allow  it  to  remain  there 
for  a  short  time.  By  holding  the  hand  in  front  of  the  urethral 
orifice,  it  will  be  possible  to  tell  if  the  urine  is  expelled  or  not. 
The  administration  of  a  couple  of  drachms  of  cold  water,  while  the 
infant  is  in  the  bath,  is  also  said  to  assist  in  causing  micturition. 
If  these  measures  fail,  and  if  the  bladder  is  distended,  a  catheter 
must  be  passed.     If  there  is  no  obstruction  present,  there  will 


AVERAGE   WEIGHT  OF  AN  INFANT  1085 

not  be  any  difficulty  in  passing  a  No.  1  or  2  catheter  in  the  case 
of  a  male  infant,  or  a  small-sized  female  catheter  in  the  case  of  a 
female  infant. 

The  meconium  is  the  term  applied  to  the  dark-green  fluid 
motions  that  are  passed  by  the  infant  during  the  first  few  days 
after  birth.  The  name  meconium  is  derived  from  the  resemblance 
which  the  stools  bear  to  thick  poppy-juice  (firjKwv,  a  poppy). 
The  motions  are  composed  chiefly  of  mucus  coming  from  the 
small  intestine,  mixed  with  bile  and  desquamated  epithelial 
cells.  In  from  one  to  three  days,  according  to  the  freedom  with 
which  the  bowels  act,  the  stools  assume  the  usual  yellow  colour 
of  an  infant's  motions.  They  number  from  two  to  five  in  the 
day,  are  fluid  in  consistency,  and  slightly  faecal  in  odour.  If  the 
infant  does  not  pass  any  meconium  within  the  first  twenty-four 
hours  after  birth,  there  probably  is  some  congenital  occlusion  in 
the  neighbourhood  of  the  anus  or  rectum.  Such  occlusions  are 
due  to  the  non-completion  of  the  process  of  fusion  between  the 
blind  end  of  the  hind  gut  and  the  anal  invagination  of  the  embryo. 
The  most  common  site  of  obstruction  is  at  the  anus,  but,  on  the 
other  hand,  there  may  be  a  properly  formed  anus  and  anal  in- 
vagination, with  a  membranous  septum  persisting  between  the 
latter  and  the  bowel,  or  the  lower  part  of  the  rectum  may  be 
wanting  and  only  represented  by  a  fibrous  cord.  With  a  view  to 
recognising  the  existence  of  such  conditions,  whenever  the  infant 
does  not  pass  meconium  within  a  few  hours  of  its  birth,  the 
medical  attendant  should  carefully  examine  the  orifice  of  the  anus, 
and  should  then  pass  the  tip  of  the  little  finger  through  the  orifice 
in  order  to  ascertain  that  the  canal  is  patent.  If  any  obstruction 
is  present,  it  must  be,  if  possible,  removed  at  once  and  the 
patency  of  the  canal  established.  If  this  course  is  not  possible, 
an  artificial  anus  must  be  made  through  the  abdominal  wall. 
The  prognosis  of  these  cases  is  serious,  as  infants  of  this  age 
stand  surgical  procedures  very  badly. 

The  average  weight  of  the  infant  at  birth  is  about  seven  pounds. 
During  the  first  two  or  three  days,  there  is  usually  a  loss  of 
weight  of  about  half  a  pound,  but  as  soon  as  the  cord  has  separated 
and  commenced  to  cicatrise,  the  infant  begins  to  regain  its  weight, 
and,  by  the  end  of  the  seventh  or  eighth  day,  is  usually  as  heavy 
as  it  was  at  birth.  From  this  time  onwards,  it  should  gain  weight 
steadily,  and  any  failure  to  do  so  shows  that  something  is  wrong, 
and  that  either  the  infant  is  suffering  from  some  unrecognised 
complaint  that  interferes  with  its  assimilation  of  food,  or  that  the 
food  it  is  receiving  is  not  of  the  proper  nature.  A  gradual  and 
regular  gain  in  weight  is  one  of  the  most  important  and  reliable 
indications  that  the  infant  is  thriving,  while  a  cessation  to  gain 
weight,  or  a  loss  in  weight,  is  conclusive  evidence  of  the  opposite. 
It  is  strange  how  difficult  it  is  to  persuade  even  intelligent  and 
trained  nurses  of  the  necessity  of  weighing  an  infant  regularly, 
especially  when   it   is    bottle-fed.      On   this   account,  it  is  most 


io86 


THE  INFANT 


important  that  the  medical  man  should  personally  insist  on  the 
infant  being  weighed  weekly,  and  that  if  it  is  found  not  to  have 
gained  in  weight,  he  should  ascertain  the  cause  of  its  failure  to  do 
so.  The  following  table  shows  the  average  daily  and  monthly 
increase  in  weight  of  an  infant,  commencing  with  an  initial  weight 
of  seven  pounds  nine  ounces  (Fleischmann) : — 


Month. 

Daily 

Increase. 

Monthly  Increase. 

Weight. 

oz. 

drms. 

oz.   drms. 

lb.     oz.  drms. 

ISt     - 

i 

3  7 

37       ° 

9      14       0 

2nd  - 

i 

2-0 

33     14 

11      15      14 

3rd  - 

0 

158 

29     10 

13     13       8 

4th  - 

o 

I2'4 

23       4 

15       4     12 

5th  - 

0 

IOI 

19       1 

16       7     13 

6th  - 

o 

T9 

14     13 

17       6     10 

7th  - 

o 

67 

12     n 

18       3       5 

8th  - 

o 

5-6 

10       9 

18     13     14 

9th  - 

0 

56 

10       9 

19       8       7 

ioth  - 

0 

5'o 

9       8 

20       1     15 

nth  - 

o 

4 '5 

8       7 

20     10       6 

12th  - 

o 

33 

6      5 

21       0     11 

INFANT  FEEDING 

There  are  three  methods  by  which  an  infant  may  be  fed  : — 

(1)  Breast  feeding  by  the  mother. 

(2)  Breast  feeding  by  a  wet-nurse. 

(3)  Artificial  feeding. 

Breast-feeding  by  the  Mother. — This  is  the  natural  method  of 
feeding  an  infant,  and  should  be  adopted  in  all  cases  in  which  it  is 
possible,  unless  there  is  a  direct  reason  to  the  contrary  on  the 
part  of  the  mother  or  of  the  infant.  The  mother  should  not  nurse 
the  infant  for  her  own  sake  if  she  is  in  a  debilitated  condition 
owing  to  previous  or  present  disease,  or  to  haemorrhage  before  or 
during  labour.  She  should  not  nurse  the  infant  for  its  sake,  if  she 
is  suffering  from  any  disease  which  she  may  communicate  to  it, 
as  phthisis,  recently  acquired  syphilis,  or  any  other  infectious 
disease ;  if  her  milk  is  insufficient  in  quantity  or  quality  ;  or  if 
she  suffers  from  any  inflammatory  condition  of  the  breasts. 
Occasionally,  the  condition  of  the  nipples  may  prevent  nursing, 
either  because  of  their  faulty  shape — depressed  nipples,  or  because 
of  the  pain  which  the  presence  of  fissures  causes  during  nursing. 
Difficulties  from  such  causes  can,  however,  as  a  rule,  be  over- 
come. If  the  nipples  are  depressed,  the  mother  can  usually  nurse 
the  infant  through  a  nipple  shield  or  a  tetarelle  (v.  Fig.  460), 
while  sometimes  it  is  possible  to  improve  their  shape.  Fissures 
only  cause  a  temporary  interference  with  nursing,  as  they  can 


CONSTITUENTS  OF  MILK 


1087 


be  easily  cured,  and,  until  this  is  done,  nursing  can  usually  be 
rendered  painless  by  the  use  of  a  nipple  shield. 

If  the  mother  decides  to  nurse  the  infant,  the  latter  should  be 
put  to  the  breast  as  soon  as  the  mother  is  comfortably  settled 
after  labour.  The  object  of  this  is  twofold.  The  act  of  suckling 
reflexly  promotes  the  contractions  of  the  uterus,  and  the  colos- 
trum, that  is,  the  first  fluid  that  comes  from  the  breast,  acts  as  a 
mild  purgative  by  virtue  of  the  slightly  increased  quantity  of  salts 
which  it  contains,  and  so  exerts  a  beneficial  effect  on  the  infant 
by  clearing  away  the  meconium.  From  this  on,  the  baby  may 
be  put  to  the  breast  every  four  hours  until  lactation  is  established, 
i.e.,  about  the  second  day,  from  which  time  onwards  it  must  be 
fed  more  frequently. 

The  average  composition  of  colostrum,  human  milk,  and  cow's 


Fig.  460. — A  Tetarelle. 

milk  is  placed  side  by  side  in  the  following  table  for  purposes 
of  comparison.  The  colostrum  analysis  is  that  obtained  by 
Pfeiffer  from  the  results  of  five  cases  ;  the  analysis  of  human  milk 
is  based  on  the  results  of  Pfeiffer,  Harrington,  Leeds,  and  others ; 
and  the  analysis  of  cow's  milk  is  based  on  upwards  of  140,000 
analyses  collected  from  various  sources  (Holt):  — 


Constituents. 

Colostrum. 

Human  Milk. 

Cow's  Milk. 

Proteids  (caseine  and 

lact-albumin) 
Fat     - 

Sugar  (lactose) 
Salts  - 
Water 

571 
2*04 

374 
0-28 

88-23 

1-50 
4-00 

7-00 

0-20 
873O 

4-00 
350 

43° 

070 

87-50 

IOO'OO 

IOO'OO 

IOO'OO 

Specific  gravity          -          T040  to  1046 
Reaction         -             -      strongly  alkaline 

1010  to  1040 
slightly  alkaline 

1028  to  1033 
usually  acid 

The  proteids  in  milk  are  in  all  probability  caseinogen  and 
lactalbumin,  to  which  a  third — lactoglobulin — has  been  added. 
Clinically,  however,  the  last  named  may  be  considered  as  identical 


2-25 

2  85 

377 

2347 

833 

1205 

2177 

o'37 

10000 

1088  THE  INFANT 

with  lact-albumin  (Rotch).  The  relative  proportion  in  which 
these  substances  occur  in  human  and  cow's  milk  is  shown  by 
the  following  figures  taken  from  Koenig  : — 

Human  Milk.  Cow's  Milk. 

Petcentage.  Percentage. 

Caseinogen                        -             o-5g  -             -             2-88 

Lact-albumin      -                         123  -            053 

Total  proteids     -  -  T/82  -  -  341 

The  practical  importance  of  this  difference  will  be  seen  when 
discussing  the  preparation  of  cow's  milk  for  infant  feeding. 

The  salts  found  in  human  milk  consist  of  the  following 
(Rotch-)  :— 

Calcium  phosphate        -  .  -  -  -     23  87 

Calcium  silicate  -  -  -       127 

Calcium  sulphate 

Calcium  carbonate 

Magnesium  carbonate 

Potassium  carbonate     - 

Potassium  sulphate       -  -  ' 

Potassium  chloride 

Sodium  chloride 

Iron  oxide  and  alumina 


The  relative  composition  of  human  milk  and  its  effect  upon 
the  infant  are  affected  by  various  conditions,  and  as  this  is  of 
considerable  practical  importance,  we  have  drawn  the  following 
short  account  of  the  most  important  of  these  conditions  from 
Holt's  t  work  : — 

The  Age  of  the  Mother. — This  produces  no  constant  effect. 
The  milk  of  very  young  women  and  of  those  above  thirty-five  is 
likely  to  contain  a  smaller  proportion  of  fat  than  the  normal. 

Number  of  Pregnancies. — This  produces  no  constant  effect. 

Acute  Illness. — If  of  a  minor  character  and  short  duration,  this 
produces  no  important  effect.  If  of  a  severe  and  febrile  type, 
the  quantity  of  milk  is  reduced,  the  fat  is  low,  and  the  proteids 
high.     In  septic  conditions,  bacteria  may  appear  in  the  milk. 

Menstruation. — The  effects  of  menstruation  are  variable  and  are 
not  generally  understood.  In  all  probability  none  of  importance 
are  produced.  On  the  other  hand,  from  observations  on  685  cases, 
Meyer  noted  disturbances  in  the  child  in  over  one-half  the  number. 
In  a  case  recorded  by  Rotch,  the  proportion  of  fat  was  low  and 
of  proteids  high. 

Diet. — The  proportion  of  fats  and  proteids  is  considerably 
influenced  by  diet,  while  the  proportion  of  sugar  is  very  little 
influenced.  A  nitrogenous  diet  increases  uniformly  both  fat 
and  proteid,  a  vegetable  diet  diminishes  both.  A  starvation 
diet  diminishes  the  fat,  while  the  proteids  may  be  increased 
or   diminished ;    if  the   former,    they   are   generally   changed   in 

*   '  Pediatrics,'  third  edition,  p.  131.  t  Op.  cit. 


BREAST-FEEDING  BY  A    WET-NURSE  1089 

character.  A  very  rich  diet  increases  fats  and  usually  proteids 
also.  All  fluids  tend  to  increase  the  quantity  of  milk.  Alcohol 
in  the  form  of  malt  drinks  and  malt  extracts  increases  the  quantity 
of  milk  and  the  amount  of  fat ;  the  effect  upon  the  proteids  is  not 
constant,  but  they  are  probably  increased. 

Drugs. — The  effect  of  drugs  is  very  uncertain  and  variable,  and 
is  more  noticeable  when  the  milk  is  poor  in  quality.  The  most 
important  drugs  which  affect  the  infant  are  belladonna,  opium, 
iodide  of  potassium,  bromides  and  mercury,  saline  cathartics, 
arsenic,  and  the  salicylates.     Acids  and  chloral  are  without  effect. 

Period  of  Lactation. — The  most  important  changes  which  occur 
in  the  milk  take  place  during  the  first  two  weeks,  and  nearly  all 
changes  occur  during  the  first  month.  During  the  first  fortnight, 
the  proteids  fall  from  nearly  four  to  below  two  per  cent.  (Pfeiffer), 
and  the  salts  from  0*45  to  0*20  per  cent.,  while  the  sugar  rises 
from  two  to  six  per  cent.,  and  there  is  a  slight  increase  in  fat. 
After  the  first  month,  the  variations  are  so  slight  that  they  may  be 
ignored  until  near  the  end  of  lactation,  when  the  proteids  fall  very 
markedly. 

Pregnancy. — If  a  nursing  woman  becomes  pregnant,  the  milk 
generally  becomes  small  in  quantity  and  poor  in  quality,  especially 
in  fat. 

Nervous  Impressions. — Nervous  impressions  of  a  marked  character 
have  a  decided  and  immediate  effect  upon  the  milk.  An  infant 
who  takes  the  breast  under  these  circumstances  may  show  signs 
of  acute  indigestion,  such  as  vomiting  and  the  presence  of  un- 
digested food  in  the  stools,  or  there  may  be,  in  addition,  great 
prostration,  toxic  symptoms,  and  even  convulsions.  The  cause 
of  these  disturbances  is  not  understood.  It  is  probable  that  the 
proteids  are  at  fault,  and  that,  instead  of  the  normal  proteids, 
others  are  produced  which  possess  toxic  properties. 

Breast-feeding  by  a  Wet-nurse.  —  If  the  mother  is  unable  or 
unwilling  to  nurse  her  infant,  the  employment  of  a  wet-nurse,  so 
far  as  the  infant  is  concerned,  is  the  more  suitable  of  the  two 
methods  of  feeding  that  are  left.  Unfortunately,  the  difficulty  of 
obtaining  a  suitable  wet-nurse  is  considerable,  and  considerations 
of  expense  often  intervene,  so  that  it  is  but  seldom  that  this 
method  of  feeding  is  adopted.  In  certain  cases,  however,  in 
which  the  infant  is  not  thriving  on  the  food  it  has  been  receiving, 
and  particularly  in  cases  in  which  previous  improper  feeding  has 
caused  serious  intestinal  derangements,  the  employment  .of  a  wet- 
nurse  is  imperative  if  the  life  of  the  infant  is  to  be  saved. 

The  task  of  selecting  a  suitable  wet-nurse  is  often  a  difficult 
one,  and  though  the  medical  adviser  can  by  a  careful  examination 
of  the  proposed  nurse  decide  whether  she  is  probably  suitable  or 
certainly  unsuitable,  the  infant  itself  is  the  ultimate  judge,  and  a 
final  decision  of  suitability  can  only  be  arrived  at  when  it  is  found 
to  digest  and  to  thrive  on  the  milk.  The  following  are  the  essentials 
for  a  wet-nurse  : — 

69 


1090  THE  INFANT 

(i)  She  must  be  perfectly  healthy,  and  free  from  every  disease 
which  can  be  communicated  to  the  infant. 

(2)  She  must  be  between  twenty  and  thirty-five  years  of  age. 

(3)  Her  breasts  must  be  firm,  with  well-shaped  nipples,  and 
contain  abundance  of  milk. 

(4)  Her  own  infant  must  be  about  the  same  age  as,  or  slightly 
older  than,  the  infant  she  is  going  to  nurse,  and  must  be  thriving 
well  upon  her  milk.  Also,  she  must  be  prepared  to  give  up 
nursing  it. 

(5)  Her  character  must  be  sufficiently  good  to  allow  of  her 
being  brought  into  the  patient's  house. 

Artificial  Feeding. — At  the  present  day,  the  artificial  feeding  of 
infants  is  not  uncommonly  substituted  for  feeding  by  human  milk, 
in  consequence  of  the  necessity  for  subordinating  the  feeding  of 
the  infant  to  the  occupations  of  the  mother,  and  also,  we  fear,  in 
many  cases,  because  the  physique  of  the  mother  does  not  enable 
her  to  nurse  her  infant  with  advantage  to  either  party.  Con- 
sequently, artificial  feeding  is  too  frequently  adopted,  and -though 
within  the  last  couple  of  decades  great  advances  have  been  made 
in  the  theory  of  infant  feeding,  still,  they  cannot  be  said  to  be 
commensurate  with  the  growth  of  the  practice.  In  other  words, 
we  fear  that  the  net  result  of  the  improvements  in,  and  of  the 
increased  prevalence  of,  artificial  feeding  is  that  many  infants 
enter  upon  their  second  year  of  life  at  a  disadvantage  as  com- 
pared with  the  infants  of  a  previous  generation. 

Artificial  feeding  can  be  satisfactorily  accomplished  by  means 
of  some  modification  of  animal  milk,  other  than  human,  or  by 
means  of  some  of  the  proprietary  artificial  foods.  We  may 
dismiss  the  use  of  the  latter  in  a  couple  of  sentences.  Proprietary 
foods  are  inferior  to  cow's  milk,  save  in  occasional  cases,  in  which, 
in  consequence  of  an  enfeebled  or  disordered  digestion,  the  infant 
is  unable  to  digest  cow's  milk.  In  such  cases,  an  infant  may 
often  be  tided  over  the  first  six  months  of  its  life  by  one  or  other 
of  these  foods.  There  is  always  a  difficulty  in  selecting  the 
particular  food  which  is  suitable  for  a  particular  infant,  and  we 
must  confess  that  we  know  of  no  method  of  deciding  the  point 
save  by  noting  the  effect  on  the  infant.  We  may  select  a  suitable 
food  at  the  first  attempt,  or,  as  in  the  selection  of  a  wet-nurse, 
we  may  have  to  try  several  different  foods  before  we  find  the  one 
which  the  infant  digests  satisfactorily. 

The  milk  of  different  animals,  notably  the  mare,  ewe,  ass,  and 
goat,  have  been  occasionally  used  for  infant  feeding,  but,  on 
account  of  the  obvious  difficulties  in  obtaining  a  sufficient  supply, 
the  milk  of  the  cow  is  for  practical  purposes  the  only  one  we  need 
take  into  consideration.  We  have  already  noted  the  principal 
analytical  differences  between  cow's  milk  and  human  milk.  We 
have  seen  that  cow's  milk  contains  more  proteids  and  salts,  and 
less  fat  and  sugar  than  does  human  milk,  and,  further,  that  the 
amount  of  proteid  substance  in  cow's  milk  that  is  coagulable  by 


ARTIFICIAL  FEEDING 


1091 


an  acid,  i.e.,  caseinogen,  is  four  times  greater  than  the  non- 
coagulable  proteid,  i.e.,  lact-albumin,  while  in  human  milk  the 
amount  of  non-coagulable  proteid  is  twice  as  great  as  the 
coagulable  proteid.  Lastly,  we  knows  that  cow's  milk  as  it  is 
received  by  the  consumer  is  faintly  acid  in  reaction,  and  contains 
large  quantities  of  micro  -  organisms,  whereas  human  milk  is 
alkaline  and  sterile.  With  these  marked  differences  existing 
between  the  two  milks,  it  would  at  first  sight  seem  as  if  it 
was  imperative  to  very  greatly  modify  the  constitution  of  cow's 
milk  before  it  can  be  a  suitable  food  for  the  nursing  infant. 
Practice,  however,  does  not  lend  entire  support  to  this  very 
rational  belief,  and,  in  consequence,  we  shall  find  that,  if  we  sift 
the  large  mass  of  literature  dealing  with  the  subject  of  infant 
feeding,  opinions  are  very  widely  divided,  and  that  while  the 
majority  of  writers  teach  that  the  composition  of  cow's  milk 
should  be  so  altered  as  to  make  it  approach  that  of  human  milk 
as  nearly  as  possible,  others  advise  the  use  of  'whole  milk,'  un- 
diluted and  unaltered,  provided  that  it  is  first  carefully  sterilised. 

The  number  of  different  methods  of  modifying  or  'humanising' 
cow's  milk  is  very  considerable,  and  to  describe  each  individual 
method  would  require  a  special  work.  The  different  methods 
may  be  divided  into  two  classes,  those  which  may  be  termed 
laboratory  methods,  as  taught  by  Holt  and  Rotch,  in  which  the 
correct  percentage  of  the  different  constituents  of  milk  is  carefully 
obtained,  and  those  which  may  be  termed  clinical  methods,  in 
which  the  approximately  correct  proportions  are  obtained  more 
or  less  by  rule  of  thumb. 

Feeding  by  one  or  other  of  the  '  laboratory  methods  '  has  much 
to  recommend  it  when  it  is  carried  out  on  a  large  scale,  but,  for 
private  use,  it  is  too  complicated  in  its  working  to  be  successful. 
Nevertheless,  for  the  benefit  of  anyone  who  may  care  to  under- 
stand the  principles  on  which  it  is  based,  we  give  a  few  tables 
compiled  from  Holt's  work  on  the  subject. 

The  first  table  shows  the  percentage  of  fat,  sugar,  and  proteid, 
which  should  be  present  in  the  infant's  food  during  the  first 
twelve  months  of  its  life  : — 


Age  of  Infant. 

Fat. 

Sugar. 

Proteid. 

Per  Cent. 

Per  Cent. 

Per  Cent. 

1  st  to  14th  day   - 

2-0 

6-0 

o-6o 

2  to  4  weeks 

2-5 

6-0 

o-8o 

1  to  3  months 

3'° 

6-o 

I '00 

3  to  5       „ 

3 '5 

60 

1-25 

5  to  9       ,, 

4-0 

7'0 

2  "00 

9  to  12     ,, 

4-0 

6-0 

2-50 

69 — 2 


1092 


THE  INFANT 


These  different  proportions  can  be  obtained  by  diluting  cream 
of  a  known  strength  with  varying  proportions  of  a  solution  of 
sugar  of  a  known  strength.  The  standard  cream  and  sugar 
solutions,  which  are  recommended  for  this  purpose  by  Holt,  are 
as  follows : — 

Cream  Solutions. — (1)  A  twelve  per  cent,  cream,  that  is,  cream 
containing  twelve  per  cent,  of  fat.  This  is  obtained  by  adding 
two  parts  of  ordinary  skimmed  or  gravity*  cream  to  one  part  of 
plain  milk,  or  by  using  equal  parts  of  centrifugal  cream  and  plain 
milk. 

(2)  An  eight  per  cent,  cream,  that  is,  cream  containing  eight 
per  cent,  of  fat.  This  is  obtained  by  adding  one  part  of  gravity 
cream  to  two  parts  of  plain  milk,  or  one  part  of  centrifugal  cream 
to  three  parts  of  plain  milk. 

Sugar  Solutions. — (1)  A  six  per  cent,  solution,  made  by  dis- 
solving an  ounce  of  milk-sugar  in  sixteen  and  a  half  ounces  of 
water,  or  an  even  tablespoonful  in  six  and  a  half  ounces  of  water. 

(2)  A  seven  per  cent,  solution,  made  by  dissolving  an  ounce 
of  milk-sugar  in  fourteen  ounces  of  water,  or  an  even  table- 
spoonful  in  five  and  a  half  ounces  of  water. 

(3)  A  ten  per  cent,  solution,  made  by  dissolving  an  ounce  of 
milk-sugar  in  ten  ounces  of  water,  or  an  even  tablespoonful  in 
three  and  three-quarter  ounces  of  water. 

The  second  table  shows  the  proportion  in  which  these  various 
solutions  must  be  mixed,  in  order  to  obtain  a  milk  of  the  required 
strength  :  — 


Cream. 

Sugar. 

Percentage  of 

Parts. 

Strength. 

Parts. 

Strength. 

Fat. 

Sugar. 

Proteids. 

1 

12  per  cent. 

5 

6  per  cent. 

20 

60 

060 

1 

»»         11 

4 

■  I         i> 

2'5 

60 

080 

1 

i>         ■■ 

3 

7  per  cent. 

30 

6.0 

1  00 

1 

ii         11 

2'5 

ii         11 

35 

60 

1  20 

1 

2 

ii         ■■ 

4'° 

60 

1-30 

1 

8  per  cent. 

1 

10  per  cent. 

40 

7-0 

200 

An  easy  clinical  method  of  preparing  a  humanised  milk,  and 
one  which  furnishes  practically  similar  results,  is  shown  in  the 
following  table  : — 

*  Skimmed  cream  removed  from  milk  which  has  stood  for  twelve  hours 
contains  about  16  per  cent,  of  fat.  Centrifugal  cream  contains  about  20  per 
cent,  of  fat. 


ARTIFICIAL  FEEDING 


1093 


Age  of  Infant. 

Gravity  Cream 
(16  per  Cent.). 

Plain  Milk. 

Milk-sugar. 

Diluent. 

Drachms. 

Drachms. 

Teaspoons. 

Drachms. 

3rd  to  14th  day  - 

2i 

14 

I* 

20 

2  to  4  weeks 

3 

2 

I* 

19 

1  to  3  months     - 

4 

2 

li 

18 

3  to  5       „ 

4 

5 

i§ 

15 

5  to  9       ,, 

4 

8 

I* 

12 

9  to  12     ,, 

3i 

12 

ii 

9i 

Instead  of  milk-sugar,  half  the  quantity  of  common  sugar  may 
be  used,  and  the  usual  diluent  is  barley-water.  On  account  of  the 
large  proportion  of  proteid  coagulable  by  an  acid  which  is  con- 
tained in  cow's  milk,  the  latter  tends  to  form  a  more  dense  curd 
in  the  stomach,  and  so  is  thought  to  be  more  difficult  to  digest. 
Barley-water  is  believed  to  break  up  this  curd  in  a  mechanical 
manner,  by  separating  the  milk  into  droplets,  which  then  coagu- 
late separately.  Laboratory  experiments  have  not,  however, 
tended  altogether  to  support  this  generally  accepted  belief. 

In  addition  to  modifying  cow's  milk  in  one  of  the  foregoing 
ways,  it  is  also  necessary  to  ensure  its  sterility.  If  the  milk  comes 
direct  from  the  cow  to  the  consumer,  and  if  close  supervision  is 
exercised  to  see  that  the  process  of  milking  is  carried  out  in  a 
cleanly  manner,  and  that  the  vessels  in  which  the  milk  is  carried 
are  absolutely  clean,  it  is  unnecessary  to  sterilise  the  milk.  If, 
however,  there  is  any  doubt  as  to  its  absolute  purity,  it  is 
advisable  to  do  so.  Micro-organisms  in  milk  can  be  destroyed 
in  one  of  three  ways,  by  boiling,  by  '  sterilising,'  or  by  '  Pasteur- 
ising.' Boiling  prejudicially  effects  the  nutritive  value  of  the 
milk,  and  cannot  be  recommended.  Pasteurising  consists  in 
raising  the  milk  to  a  temperature  of  between  1580  and  1760  F., 
and  maintaining  it  at  that  temperature  for  thirty  to  forty 
minutes.  It  is  perhaps  the  best  method,  though  it  does  not 
effect  complete  sterilisation,  but  it  is  slightly  more  difficult 
to  carry  out,  and  necessitates  the  use  of  a  more  complicated 
apparatus.  The  method,  which  for  want  of  a  better  term  is 
called  'sterilising,'  consists  in  placing  the  milk  in  a  bottle  or  other 
receptacle,  which  is  three-quarters  immersed  in  water.  The 
water  is  then  raised  to  boiling  point,  at  which  it  is  kept  for  forty 
minutes.  The  most  convenient  form  of  apparatus  for  carrying 
out  this  process  is  that  devised  by  Soxhlet,  and  is  shown  in 
Fig.  461.  By  its  means,  a  number  of  bottles,  each  containing 
sufficient  for  one  feeding,  can  be  prepared  at  one  time,  and  are 
kept  from  subsequent  contamination  by  means  of  a  small  rubber 
cap,  which  is  sucked  into  the  mouth  of  the  bottle  as  the  contents 
cool. 

The  use  of  whole,  or  undiluted,  milk  is  becoming  more  common. 
It  was  first  recommended  by  Budin,  and  more  recently  has  been 


1094 


THE  INFANT 


strongly  advocated  by  other  writers.  Tweedy  has  adopted  this 
form  of  feeding  at  the  Rotunda  Hospital  with  considerable 
success,  and  our  personal  experience  of  it,  though  not  great,  is, 
on  the  whole,  satisfactory.  The  required  quantity  of  milk  is 
placed  in  the  Soxhlet  bottles,  and  then  sterilised  as  has  been 
described  for  forty  minutes.  As  even  whole  milk  is  deficient  in 
sugar,  the  deficiency  may  be  made  up  by  the  addition  of  a  little 
milk-sugar.  Similarly,  the  amount  of  fat  may  be  increased  by 
the  addition  of  cream,  or  this  may  be  given  separately  off  a  spoon. 
If  possible,  the  cream  should  be  got  from  a  source  which  does 
not  necessitate  sterilisation,  as  in  this  way  the  anti-scorbutic 
property  of  milk,  a  property  which  is  said  to  be  destroyed  by 
sterilisation,  is  restored. 

A  healthy  infant  will  thrive  on  almost  any  form  of  humanised 
milk  or  on  whole  milk.  The  latter  is  in  one  way  a  distinct 
advantage,  as  it  tends  to  promote  the  regular  action  of  the  bowels, 


Fig.  461. — The  Soxhlet  Milk  Steriliser. 

in  all  probability  in  consequence  of  the  relatively  larger  propor- 
tion of  non-assimilated  residue  which  is  left,  and  which  tends  to 
increase  markedly  the  size  of  the  stools.  We,  however,  still 
think  that  for  the  first  three  months,  at  any  rate,  some  modifica- 
tion of  the  milk  is  necessary,  after  that  time  whole  milk  may  be 
given  with  advantage. 

General  Remarks  on  Infant  Feeding. — If  the  infant  is 
breast  fed,  it  should  be  put  alternately  to  each  breast,  and  may, 
as  a  rule,  be  allowed  to  draw  as  much  as  it  wishes.  As  soon  as 
it  falls  asleep,  it  should  be  taken  from  the  breast.  The  nipples 
should  be  washed  with  a  little  warm  water  immediately  before 
feeding  and  immediately  after,  and  the  lips  should  also  be  care- 
fully wiped  with  a  soft  piece  of  old  linen  to  remove  all  traces  of 
milk.  The  number  of  feedings  in  the  day  is  the  same  whether 
breast  or  artificial  feeding  is  adopted. 

If  the  infant  is  fed  artificially,  attention  must  be  paid  not  only 
to  the  intervals  at  which  it  is  fed,  but  also  to  the  amount  it 
receives  at  each  feeding,  and  to  the  adoption  of  strict  cleanliness. 


GENERAL  REMARKS  ON  INFANT  FEEDING 


1095 


The  amount  which  is  given  at  each  meal  is  regulated  by  the 
capacity  of  the  infant's  stomach  (v.  Fig.  462).  This,  on  an 
average,  at  birth  is  one  ounce ;  at  three  months,  four  and  a  half 
ounces  ;  at  six  months,  six  ounces ;  and  at  twelve  months,  nine 
ounces  (Holt).  The  following  table,  also  based  on  Holt's  tables, 
shows  the  number  of  feedings  in  the  twenty-four  hours  during  the 
first  year  of  life,  and  the  amount  given  at  each  feeding : — 


If  the  infant  is  fed  on  whole  milk,  a  slightly  smaller  quantity 
than  is  shown  in  the  above  table  will  suffice,  but  here,  as  in  other 
cases,  we  must  be  largely  guided  by  the  special  requirements  of 
the  infant  and  by  the  effect  which  the  food  produces.  If  the 
infant  'possets'  up  unchanged  milk,  it  is  getting  too  much  fluid.  If 
it  passes  undigested  curds,  the  milk  is  too  strong.  If  it  digests  its 
food  well,  but  seems  always  to  be  hungry,  it  may  get  more  fluid 
with  proportionately  less  barley-water,  or,  if  this  disagrees,  a 
larger  quantity  of  the  usual  mixture. 

Too  little  sugar  causes  a  slower  gain  in  weight  than  is  normal ; 
too  much  sugar  causes  colic,  and  also  perhaps  thin  green  stools 
(Holt).  Too  little  fat  causes  hard  dry  stools  ;  too  much  fat  causes 
vomiting  or  regurgitation  of  food,  and  frequent  motions,  which 
sometimes  contain  whitish  lumps  composed  of  fat  (Holt).  Too 
much  proteid  matter  causes  curds  in  the  stools,  colic,  sometimes 
diarrhoea,  but  more  usually  constipation.  The  following  symptoms 
show  that  the  child  is  not  receiving  sufficient  nourishment : — 

(1)  During  the  first  three  days,  the  temperature  shows  an 
inclination  to  rise.  It  ranges  about  1010  to  1020  F.,  and  may 
even  reach  1040  F.  or  more.  This  is  the  so-called  inanition 
fever  (Holt). 

(2)  The  infant  ceases  to  gain  in  weight. 

(3)  The  infant  draws  the  breast  for  a  long  time  before  it  is 
satisfied.  If  the  milk  is  abundant,  five  or  ten  minutes  ought  to 
be  sufficient  to  satisfy  it  ;  if  the  milk  is  deficient  it  may  require 
half  an  hour  or  more. 


1096  THE  INFANT 

(4)  Its  sleep  is  irregular  and  disturbed,  and  when  awakened  it 
frequently  cries. 

(5)  The  stools  are  irregular  and  of  an  unhealthy  appearance. 
The  strictest  cleanliness  must  be  observed  both  in  the  bottles 

used  for  feeding  and  in  all  vessels  in  which  milk  is  contained. 
The  feeding-bottle  should  be  boat-shaped,  and  so  have  no  angles 
in  which  particles  of  milk  may  lodge.  The  nipple  should  fit 
directly  on  the  neck  of  the  bottle,  and  on  no  account  should  the 
use  of  any  form  of  bottle  with  an  intervening  tube  be  allowed. 


Fig.  462. — Diagram  showing  the  Actual  Size  of   an  Infant's  Stomach 
at  Different  Periods. 

A,  At  birth,  capacity  one  ounce ;  B,  at  two  weeks,  capacity  two  ounces  ; 
C,  at  three  months,  capacity  four  and  a  half  ounces ;  D,  at  six  months, 
capacity  six  ounces. 

The  bottles  should  be  washed  immediately  after  use,  and  when 
not  in  use  kept  in  a  solution  of  soda  and  water,  and  then 
again  rinsed  with  plain  water  before  use.  On  the  systematic 
observance  of  such  apparently  small  points,  the  success  of  infant 
feeding  depends,  and  if  they  are  neglected,  no  matter  how  excellent 
in  other  ways  may  be  the  system  of  feeding  adopted,  it  will  con- 
tinually break  down. 


CHAPTER  II 
THE  PATHOLOGY  OF  THE  INFANT 

Asphyxia  Neonatorum — Diseases  of  the  Alimentary  System,  Constipation, 
Diarrhcea,  Thrush — Icterus  Neonatorum — Acute  Infective  Diseases, 
Ophthalmia  Neonatorum,  Umbilical  Infection,  Mastitis  —  Traumata 
during  Birth  ;  Fractures ;  Haemorrhages,  Cephalhematoma,  Hsema- 
toma  of  Sterno  Mastoid  ;  Nerve  Lesions,  Central,  Peripheral. 

ASPHYXIA  NEONATORUM 

Asphyxia  neonatorum  is  the  term  applied  to  the  persistence  of 
complete  or  partial  apncea  after  the  birth  of  the  infant.  The  con- 
dition is  also  known  as  '  the  apparent  death  of  the  new-born.' 
Two  degrees  of  asphyxia  are  met  with — asphyxia  pallida,  or  white 
asphyxia,  and  asphyxia  livida,  or  blue  asphyxia.  In  asphyxia 
pallida,  the  infant  is  white  when  born,  its  body  flaccid,  and  its 
heart  scarcely  perceptible,  all  attempts  at  respiration  are  absent, 
and  there  is  no  response  to  cutaneous  or  other  stimulation.  In 
asphyxia  livida,  the  condition  of  the  infant  is  not  so  serious.  It  is 
of  a  blue  or  cyanotic  colour  when  born,  its  body  is  stiff,  its  heart 
beats  comparatively  strongly,  there  are  spasmodic  attempts  at 
respiration,  and  there  is  usually  a  more  or  less  vigorous  response 
to  stimulation. 

JEtiology. — The  common  cause  of  asphyxia  is  prolonged  com- 
pression of  the  foetus  during  the  second  stage  of  labour,  and 
particularly  compression  of  the  funis.  Partial  premature  detach- 
ment of  the  placenta  is  another  cause,  but,  in  such  cases,  unless 
delivery  is  rapid,  the  death  of  the  foetus  usually  occurs.  Deep 
maternal  anaesthesia  induced  by  chloroform  must,  we  think,  also 
be  reckoned  as  a  cause,  but  in  such  cases  the  recovery  of  the 
foetus  is  usually  rapid  and  complete.  The  degree  of  asphyxia 
present  depends  on  the  length  of  time  for  which  the  supply  of 
oxygen  has  been  lessened  or  cut  off. 

Treatment. — The  treatment  of  asphyxia  to  be  successful  must  be 
prompt  and  systematic.  The  chief  objects  to  be  aimed  at  are  the 
removal  of  any  substance  such  as  liquor  amnii  or  mucus  that  has 
been  sucked  into  the  throat  of  the  child  during  premature  efforts 

1097 


1098 


THE  INFANT 


at  inspiration,  the  establishment  of  respiratory  efforts,  and  the 
stimulation  of  the  heart.  If  the  infant  is  born  in  a  condition 
of  white  asphyxia,  the  cord  must  be  immediately  ligated  and 
divided,  and  the  infant  held  up  for  a  moment  by  the  heels  to  allow 
the  mucus  to  run  out  of  its  trachea,  and  then  placed  in  a  bath  of 
hot  water  (ioo°  F.).  It  is  kept  in  this  for  a  few  seconds  while 
further  attempts  are  made  to  remove  mucus  from  its  mouth  and 
larynx.     This  can  be  done  first  with  the  tip  of  the  finger  covered 


Fig.  463. — Schultze's  Method  of  Artificial  Respiration  :  Inspiration. 

by  a  piece  of  soft  linen,  and  then  by  aspirating  the  mucus  by  a 
catheter  introduced,  if  possible,  into  the  trachea,  or  by  the  special 
forms  of  aspirator  devised  by  Ribemont-Dessaignes  or  by  Gibson. 
The  baby  is  then  taken  out  of  the  bath,  quickly  dried  to  prevent 
loss  of  heat  from  surface  evaporation,  and  some  form  of  artificial 
respiration  is  performed  five  or  six  times.  At  first,  the  most 
suitable  method  is  the  swinging  movement  introduced  by 
Schultze,  and,  as  increasing  efforts  at   respiration  are  made  by 


ASPHYXIA  NEONATORUM 


1090 


the  infant,  these  may  be  replaced  by  Marshall  Hall's  method. 
When  Schultze's  movements  have  been  performed  from  six  to 
ten  times  the  infant  is  replaced  in  the  bath,  and  the  same  routine 
is  repeated.  In  performing  Schultze's  movements,  the  move- 
ments of  inspiration  and  expiration  should  be  made  at  the  rate 
of  from  eight  to  ten  in  the  minute,  and,  so  far  as  possible,  should 
be  made  to  synchronise  with  any  similar  respiratory  efforts  that 
are  being  made  by  the  infant.  This  routine  is  continued  until 
either  the  heart  stops  or  its  movements  become  stronger,  and  the 


/ 


Fig.  464. — Schultze's  Method  of  Artificial  Respiration  :  Expiration. 


dead  white  colour  and  flaccid  condition  of  the  infant  disappears. 
As  soon  as  this  occurs,  the  treatment  proper  to  blue  asphyxia 
may  be  adopted. 

If  the  infant  is  born  in  a  condition  of  asphyxia  livida,  it  is  not 
necessary  immediately  to  divide  the  cord,  as  to  do  so  deprives 
the  infant  of  a  certain  amount  of  blood.  If  the  heart  is  beating 
strongly,  all  that  is  at  first  necessary  is  to  suspend  the  infant 
by  the  heels  in  order  to  clear  its  trachea  of  mucus,  and  then  to 


noo  THE  INFANT 

remove  the  mucus  that  has  collected  in  the  mouth.  As  soon  as 
the  trachea  is  clear,  the  infant  will  usually  respond  to  cutaneous 
stimulation,  such  as  a  slap  or  a  dash  of  cold  water.  If  it  does  not 
respond  to  this,  the  cord  may  be  divided  and  the  infant  placed 
in  a  hot  bath.  The  larynx  and  mouth  are  again  cleared  as  before, 
and  the  infant  removed  from  the  hot  bath  and  plunged  for  a 
moment  into  a  cold  bath.  It  is  then  dried  and  artificial  respira- 
tion performed.  A  little  whisky  may  also  be  rubbed  on  the  gums 
and  chest,  as  the  irritation  provokes  respiration.  This  routine  is 
continued  until  the  infant  makes  fairly  regular  respiratory  efforts. 


Fig.   465. — Marshall  Hall's  Method  of  Artificial  Respiration  : 
Inspiration. 


Then,  the  nurse  should  take  the  infant  on  her  lap  in  front  of  a 
fire,  and  perform  Marshall  Hall's  method  of  artificial  respiration. 
These  movements  assist  respiration,  and,  at  the  same  time,  prob- 
ably promote  the  circulation  of  the  blood  and  so  assist  the  action 
of  the  heart.  They  should  be  continued  until  normal  respiration 
is  completely  established,  and,  subsequently,  if  a  condition  of 
partial  or  complete  apnoea  should  supervene,  they  must  be  re- 
peated. 

In  view  of  the  many  not  alone  incorrect,  but  even  impossible 
descriptions  which  have  been  given  of  Schultze's  method  of 
artificial  respiration,  it  may  be  of  interest  to  describe  it  as  nearly 
as  possible  in  his  own  words. 


ASPHYXIA  NEONATORUM  1101 

The  child,  lying  upon  its  back,  is  grasped  by  the  shoulders,  the 
open  hands  having  been  slipped  beneath  the  head.  The  three 
last  fingers  remain  extended  in  contact  with  the  back,  while  each 
index  finger  is  inserted  into  an  axilla,  the  thumbs  lying  upon  and 
in  front  of  the  shoulders  (v.  Fig.  463).  When  the  child  thus  held 
is  allowed  to  hang  suspended,  its  entire  weight  rests  upon  the  two 
fingers  in  the  armpits.  It  is  now  swung  forwards  and  upwards, 
and  the  operator's  hands  going  to  the  height  of  his  own  head,  the 
pelvic  end  of  the  child  rises  above  its  head  and  falls  slowly  towards 
the  operator  by  its  own  weight,  flexion  occurring  in  the  lumbar 


Fig.   466. — Marshall  Hall's  Method  of  Artificial  Respiration 
Expiration. 


region  (v.  Fig.  464).  The  thumbs  in  front  of  the  shoulders  com- 
press the  chest,  while  the  hyper-flexed  lumbar  vertebra?  and  pelvis 
compress  the  abdomen,  and  through  it  the  thorax  ;  finally,  the 
three  last  fingers  on  each  side  compress  the  thorax  laterally.  As  a 
result  of  this  manoeuvre  when  properly  done,  aspirated  secretions 
flow  freely  from  the  mouth.  The  distended  heart  also  feels  the 
compression,  which  forces  the  blood  into  the  arteries.  The  child 
is  now  swung  back  into  its  original  position,  and  supported 
entirely  by  the  fingers  in  the  axilla?.  The  compression  of  the 
thumbs  and  the  three  last  fingers  is  removed.  The  downward 
swing  elevates  the  sternum  and  ribs,  while  gravitation  and  the 
traction  of  the   intestines   depress  the  diaphragm.     It   is   often 


uo2  THE  INFANT 

possible  to  hear  the  air  rush  into  the  infant's  glottis  as  it  reaches 
the  original  position,  although  this  can  also  occur  in  a  cadaver. 
The  amplification  of  the  thorax  lowers  the  intracardiac  pressure. 
The  child  should  be  swung  up  and  down  ten  times  for  the  space 
of  a  minute. 

We  prefer  to  hold  the  infant  as  has  been  described,  save  that 
instead  of  passing  the  index  fingers  from  behind  into  the  axillae, 
pass  the  thumbs  from  in  front,  keeping  the  index  fingers  along 
the  sides  of  the  chest.  Then,  raise  the  body  with  a  quick  sweep 
through  the  air  until  it  reaches  the  vertical,  when  it  is  allowed 
to  gently  roll  forward  on  to  the  thumbs,  which  have  been  taken 
out  of  the  axillae  and  placed  under  the  chest.  The  child  is  then 
swung  forward  as  before,  and  the  thumbs  at  the  same  time  are 
slipped  back  into  the  axillae. 

Marshall  Hall's  rolling  method  of  artificial  respiration  is  per- 
formed as  follows  : — The  medical  man  or  nurse  sits  on  a  low 
chair,  preferably  near  a  fire,  and  lays  the  infant  on  its  back  across 
his  or  her  knees,  as  shown  in  Fig.  465.  He  then  grasps  the  right 
arm  of  the  infant  in  his  left  hand,  at  the  same  time  steadying  the 
breech  by  the  pressure  of  the  right  hand.  The  infant  is  then 
rolled  over  on  to  its  left  side,  and  the  thorax  compressed  with  the 
left  hand,  as  shown  in  Fig.  466.  This  causes  expiration.  The 
infant  is  then  rolled  back  into  its  former  position,  and  at  the  same 
time  its  right  arm  is  drawn  forwards  and  upwards  in  such  a 
manner  as  to  cause  an  upward  traction  on  the  ribs.  This  move- 
ment causes  an  increase  in  the  diameters  of  the  chest,  and  so 
favours  inspiration.  The  movements  are  repeated  rhythmically  at 
a  rate  of  from  ten  to  twelve  in  the  minute,  and  may  be  continued 
for  an  hour  or  more. 


DISEASES  OF  THE  ALIMENTARY   SYSTEM 

Constipation. — Constipation  is  one  of  the  most  common  of  the 
minor  ailments  of  infancy  and  also  one  of  the  most  important,  as, 
although  it  is  itself  a  minor,  ailment,  its  effects  are  far-reaching. 
In  the  young  infant  it  is  due,  in  almost  all  cases,  to  improper 
food,  and  consequently  it  is  rare  in  the  case  of  infants  breast- 
fed by  a  healthy  mother.  When  it  occurs  in  such  cases,  it  will 
usually  be  found  to  be  due  to  an  insufficient  proportion  of  fat  in 
the  milk,  or  to  be  associated  with  constipation  in  the  mother. 
Constipation  in  bottle  fed  infants  is  similarly  very  commonly  due 
to  an  insufficiency  of  fats,  or  to  an  insufficiency  of  both  fats  and 
proteids.  In  the  latter  case,  the  immediate  cause  is  probably  the 
want  of  a  sufficient  residuum  in  the  bowel  to  stimulate  peristaltic 
movements. 

Treatment. — The  treatment  of  constipation  should  be  essentially 
prophylactic.  An  infant  normally  passes  from  three  to  five  liquid 
motions  in  the  day,  and  these  are  passed  without  any  straining. 


CONSTIPATION  AND  DIARRHCEA  1103 

If  the  motions  become  lumpy  and  hard,  and  the  amount  scanty, 
immediate  steps  should  be  taken  to  bring  them  back  to  their 
normal  condition.  The  use  of  drugs  should  be  if  possible  avoided, 
and,  instead,  the  quality  of  the  food  changed.  If  the  infant  is 
breast-fed,  the  health  of  the  mother  must  be  attended  to,  her 
dietary  increased  in  fats  and  proteids,  and  any  tendency  on  her 
part  to  constipation  corrected  by  the  use  of  laxatives.  In  bottle- 
fed  infants,  the  nature  of  the  food  which  the  infant  is  getting  must 
be  ascertained.  As  a  rule,  it  will  be  necessary  to  increase  the 
amount  of  fat  by  the  addition  of  cream,  or  by  the  administration 
of  a  few  drops  of  cod-liver  oil  two  or  three  times  in  the  day.  The 
use  of  pure  sterilised  milk  in  these  cases  is  often  of  advantage,  as 
it  causes  a  large  increase  in  the  size  of  the  stool,  and  so  increases 
peristalsis.  If  sterilisation  has  been  previously  effected  by  boiling 
this  practice  should  be  stopped,  and  the  infant  given  either  pure 
unsterilised  milk- — if  the  supply  is  trustworthy,  or  the  milk 
sterilised  in  the  manner  we  have  already  described.  The  effect 
of  boiling  is  always  prejudicial. 

If  these  measures  are  insufficient,  constipation  may  be  relieved 
by  rectal  stimulation,  as  by  the  use  of  enemata  or  small  sup- 
positories. These  measures  are  unlikely  to  have  permanently 
good  effects,  save  in  cases  in  which  the  cause  of  the  constipation 
is  to  be  found  in  feebleness  of  the  expulsive  powers  of  the  rectum. 
In  such  cases,  enemata  of  one  to  two  ounces  of  soap  and  water, 
half  an  ounce  of  olive  oil,  or  a  drachm  of  glycerine,  or  sup- 
positories made  of  soap  or  of  a  small  cone  of  oiled  paper,  are  of 
use.  Glycerine  has  a  powerful  effect,  but  its  continued  use  may 
cause  irritation  of  the  rectal  mucous  membrane,  as  also,  though 
to  a  less  degree,  does  the  continued  use  of  soap. 

The  use  of  drugs  is,  as  Holt  says,  the  least  important  part  of 
the  treatment  of  chronic  constipation,  and  this  remark  applies  as 
well  to  infants  as  to  older  children.  In  many  cases,  the  value  of 
an  occasional  laxative  or  purgative  is  considerable,  and  its  ad- 
ministration is  always  necessary  when  the  infant  has  been  con- 
stipated for  some  time,  but  its  habitual  use  is  most  prejudicial, 
and  is  a  confession  that  the  system  of  feeding  has  broken  down. 
Of  the  various  drugs  in  general  use,  the  least  harmful  are  perhaps 
the  Syrup  of  Senna  in  doses  of  a  half  to  one  teaspoonful, 
and  Phosphate  of  Soda  in  doses  of  three  to  five  grains.  For 
long-continued  use,  or  in  cases  which  do  not  respond  to  the  afore- 
mentioned drugs,  Cascara  Sagrada  in  from  one  to  five  minim 
doses,  sweetened  by  the  addition  of  a  few  drops  of  glycerine,  is 
useful.  Castor  oil  is  always  contra-indicated  in  cases  of  simple 
constipation,  as  so  far  from  relieving,  it  tends  to  promote  the 
condition. 

Diarrhoea. — We  are  here  concerned  with  diarrhoea  the  result 
of  acute  intestinal  indigestion,  brought  on  by  improper  or  impure 
food.     Although  this  form  of  indigestion  is  a  preventable  disease, 


no4  THE  INFANT 

it   is   one   of  the   commonest    causes   of    infant    morbidity   and 
mortality. 

Aitiology. — Acute  intestinal  indigestion  may  occur  in  breast-fed 
infants,  but  it  is  very  much  more  common  in  the  case  of  those 
who  are  artificially  fed.  In  the  former  case,  a  toxic  condition  of 
the  milk  may  result  from  septic  or  from  other  acute  febrile  diseases 
of  the  mother  and  from  severe  mental  emotions,  or  the  amount  of 
proteid  contained  in  the  milk  may  be  so  great  that  undigested 
masses  are  left  in  the  stomach  or  intestines  and  give  rise  to 
irritation.  Such  irritation  is  also  especially  prone  to  occur  in  the 
case  of  artificial  feeding,  and  in  addition  the  risks  of  the  ingestion 
of  toxic  milk  by  the  infant  are  greatly  increased.  The  commonest 
cause  of  diarrhoea  in  bottle-fed  infants  is  the  administration  of 
sour  milk  due  to  a  defective  milk-supply  or  to  the  use  of  dirty 
bottles.  There  is  no  doubt  that  some  infants  are  more  prone  to 
diarrhoea  than  others,  and  that,  in  such,  a  smaller  variation  from 
the  normal  in  the  food,  or  a  slighter  degree  of  toxicity  of  the  milk, 
will  be  sufficient  to  cause  trouble.  Similarly,  if  an  infant  has 
once  had  an  attack  of  '  green  diarrhoea,'  it  will  be  prone  to  future 
attacks. 

Symptoms. — The  characteristic  appearance  of  the  motions  in 
these  cases  is  described  by  the  term  '  green  diarrhoea.'  The 
stools  vary  in  colour  from  a  bright  grass-green  to  a  dark  greenish- 
brown,  and  usually  contain  mucus  and  whitish  lumps,  consisting 
of  masses  of  undigested  proteid  or  fat.  The  number  of  motions 
in  the  day  varies  from  five  or  six  to  a  practically  continuous 
diarrhoea.  As  a  rule,  vomiting  also  occurs,  and  the  infant  vomits 
up  sour-smelling  and  curdled  masses.  If  these  symptoms  have 
continued  for  some  days,  the  appearance  of  the  infant  becomes 
greatly  altered,  its  face  and  limbs  are  wasted,  its  appearance 
anxious  and  '  aged,'  and  its  eyes  large  and  staring.  It  is  extremely 
irritable,  and  cries  frequently  as  if  in  pain.  Convulsions,  twitch- 
ings,  and  temporary  rigidity  of  the  limbs  and  trunk  muscles  occur 
in  the  later  stages,  and  in  the  worst  cases  the  appearance  of  the 
infant  may  at  times  suggest  that  death  has  occurred.  Even  such 
cases,  however,  may  recover  under  suitable  treatment. 

Treatment.  —  The  prophylactic  treatment  of  green  diarrhoea 
consists  in  careful  attention  to  the  nature  of  the  food  and  to  the 
manner  in  which  it  is  given.  A  method  of  feeding  which  is  quite 
satisfactory  with  one  infant  may  be  unsuccessful  with  another. 
If  a  breast-fed  baby  suffers  from  diarrhoea  and  does  not  gain  in 
weight,  and  if  the  usual  methods,  which  we  are  about  to  describe, 
have  not  the  desired  effect,  it  is  better  to  stop  the  mother  nursing, 
and  to  resort  to  a  wet-nurse  or  to  artificial  feeding.  The  longer 
the  unsuitable  food  is  continued,  the  more  difficult  it  will  be  to 
bring  the  gastro-intestinal  tract  back  to  a  normal  condition. 
Similarly,  in  the  case  of  a  bottle-fed  infant,  if  the  diarrhoea 
cannot  be  checked,  the  food  must  be  changed  at  once.  If  the 
change  from  one  artificial  food  to  another  does  not  bring  about 


THRUSH  1 105 

a   speedy  improvement,  the  employment  of  a  wet-nurse  is  im- 
perative. 

The  only  rational  medicinal  treatment  in  these  cases  consists 
in  the  administration  of  purgatives,  with  the  object  of  removing 
all  curdled  and  decomposing  masses  from  the  intestinal  tract, 
of  intestinal  antiseptics,  and  lastly,  if  necessary,  and  if  we  are 
sure  that  all  offending  matter  has  been  removed,  of  intestinal 
sedatives.  The  latter  are,  however,  directly  contra-indicated  as 
long  as  fermenting  and  irritating  masses  are  retained.  In  all 
cases,  we  commence  with  the  administration  of  castor  oil  in  half 
to  one  drachm  doses,  repeated  if  necessary.  This,  if  associated 
with  the  necessary  alteration  in  the  food,  is  usually  sufficient.  If 
it  is  not  sufficient,  the  repeated  administration  of  small  doses  of 
grey  power  or  of  calomel,  either  alone  or  in  association  with  salol, 
may  be  tried.  A  suitable  prescription  in  such  cases  for  an  infant 
in  the  first  three  months  is  as  follows  : — 

fy     Hydrarg.  c.  Creta        -         -         -     gr.  J 
Salol    -         -         -         -         -         -     gr.  § 

Sacchari  Lactis   -         -         -         -ad  grs.  2. 

One  of  these  powders  may  be  given  night  and  morning,  and  a 
similar  powder  from  which  the  grey  powder  has  been  omitted 
may  be  given  every  sixth  hour.  If  the  intestinal  tract  has  been 
emptied,  but  frequent  motions  consisting  mainly  of  mucus  and 
perhaps  of  a  little  blood  continue,  minute  doses  of  Dover's  powder 
may  be  given,  or  if  the  possible  effect  of  the  opium  is  dreaded, 
subnitrate  of  bismuth,  chalk  mixture,  or  even  small  doses  of  the 
tincture  of  the  perchloride  of  iron.  At  the  same  time  all  food 
may  be  peptonised,  in  order  to  assist  the  weakened  action  of  the 
gastric  juice.  If  the  diarrhcea  resists  these  measures,  or  if  the 
infant  is  in  a  condition  of  marasmus,  the  employment  of  a  wet- 
nurse  is  imperative,  and,  in  many  cases,  offers  the  only  prospect 
of  saving  the  life  of  the  infant.  In  cases  of  extreme  marasmus, 
stimulants  such  as  brandy  or  champagne  must  be  given  with 
comparative  freedom,  in  small  doses  well  diluted  and  frequently 
repeated. 

Thrush.  —  Thrush,  like  constipation  and  diarrhcea,  is  in- 
timately connected  with  a  faulty  system  of  feeding.  It  is  a 
parasitic  stomatitis,  which  is  characterised  by  the  appearance  of 
white  patches  on  the  tongue,  palate,  or  buccal  mucous  membrane. 
The  invading  fungus  is  usually  stated  to  be  the  Oidium  Albicans,  but 
according  to  Holt  this  is  not  the  case,  and  the  fungus  belongs  to 
the  groups  of  saccharomyces,  and  so  is  termed  the  Saccharomyces 
Albicans.  The  infection,  as  a  rule,  comes  from  a  dirty  bottle 
or  nipples,  and,  consequently,  thrush  may  occur  in  the  case 
of  either  a  breast-  or  a  bottle-fed  infant.  The  spores  of  the 
fungus  lodge  between  the  epithelial  cells,  and  thence  gradually 
extend  so  as  to  form  a  white  patch  on  the  surface  of  the  mucous 

70 


uo6  THE  INFANT 

membrane.  The  diagnosis  is  readily  made  from  the  appearance 
of  these  patches,  or  if  a  little  of  the  patch  is  gently  scraped  away 
and  placed  upon  a  slide  with  a  drop  of  Liquor  Potassae,  the 
threads  of  the  fungus  are  easily  seen  with  a  low  power  of  the 
microscope. 

Symptoms. — The  symptoms  which  accompany  thrush,  other  than 
those  of  a  slightly  irritating  stomatitis,  are  generally  due  to  an 
accompanying  gastro-intestinal  irritation  brought  about  by  impure 
food.  Accordingly,  thrush  is  frequently  found  in  association 
with  green  diarrhoea  and  vomiting.  It  is  not  in  itself  a  dangerous 
condition,  and  the  debility  of  the  infant  with  which  it  is  associated 
is  rather  the  favouring  factor,  which  permits  the  development  of 
the  fungus,  than  the  consequence  of  its  presence. 

Treatment. — The  treatment  is  essentially  prophylactic,  as  in 
the  case  of  diarrhoea,  and  consists  in  attention  to  the  purity  of 
the  food  and  the  cleanliness  of  the  bottles  through  which  the 
food  is  administered.  Also,  the  nipples  of  the  mother  should  be 
washed  before  nursing,  and  the  mouth  of  the  infant  should  be 
gently  washed  out  after  feeding  with  a  soft  piece  of  old  linen  and 
warm  water.  If  thrush  occurs  in  spite  of,  or  rather  for  want  of, 
these  precautions,  it  is  easily  cured  by  the  application  of  any 
mild  antiseptic  mouth-wash,  such  as  a  little  glycerine  of  borax,  or 
boric  lotion. 


ICTERUS  NEONATORUM 

Icterus  neonatorum  is  the  term  applied  to  jaundice  occurring  in 
the  newly-born  infant. 

/Etiology.  —  Icterus  in  the  new  born,  as  in  the  adult,  is  a 
symptom  of  several  different  conditions.  The  severe  form,  which 
is  known  as  grave  or  malignant  icterus,  is  the  result  of  extensive 
disease  of  the  liver  or  of  the  bile  -  ducts,  and  so  is  found  in 
syphilitic  hepatitis,  in  septic  infection  travelling  through  the 
umbilical  vessels,  and  in  congenital  malformations  of  the  bile- 
ducts.  This  form  is  fortunately  rare,  and  is  in  most  cases  in- 
curable. The  common  form  of  icterus,  with  which  we  are  here 
concerned,  is  that  known  as  physiological  or  idiopathic  icterus.  It 
occurs  in  about  sixteen  per  cent,  of  infants,  as  is  shown  by 
statistics  compiled  by  Purefoy*  at  the  Rotunda  Hospital.  Its 
causation  is  obscure,  and  many  theories  have  been  brought  for- 
ward to  account  for  it.  Of  these,  the  one  most  generally  received 
is  that  advanced  by  Silbermann,  to  the  effect  that  the  icterus 
is  hepatogenous  in  origin  and  is  due  to  the  resorption  of  bile, 
this  resorption  being  favoured  by  the  stasis  of  bile  in  the  capillary 
bile-ducts,  the  result  of  their  compression  after  birth  by  the 
dilated  portal  vein  and  hepatic  blood  capillaries.     The  amount  of 

*  Reports  of  the  Rotunda  Hospital,  Trans.  Roy.  Acad,  of  Medicine  in  Ireland, 
vol.  xviii.,  1900,  p.  277. 


OPHTHALMIA  NEONATORUM  AND  UMBILICAL  INFECTION     1107 

bile-pigment  in  the  liver  is  also  increased,  owing  to  the  breaking 
down  of  large  quantities  of  red  blood  corpuscles. 

Treatment.  —  Simple  icterus  calls  for  no  treatment.  If  the 
bowels  are  confined,  one  or  two  grains  of  phosphate  of  soda  may 
be  given. 


ACUTE  INFECTIVE  DISEASES 

Ophthalmia  Neonatorum. — Ophthalmia  in  new-born  infants 
is  usually  the  result  of  infection  of  the  eyes  during  the  passage 
of  the  head  through  the  vagina.  It  may  also  occur  after  birth 
as  a  result  of  infection  conveyed  by  the  fingers  of  the  nurse 
or  mother.  As  a  rule,  it  is  due  to  the  inoculation  of  the  gono- 
coccus,  but  more  rarely  it  may  be  due  to  some  of  the  other  forms 
of  pyogenic  bacteria.  The  symptoms  commence  about  two  days 
after  infection,  and  consist  of  swelling  of  the  lids,  injection  of  the 
conjunctiva,  and  profuse  purulent  discharge.  The  later  conse- 
quences of  the  infection  may  be  ulceration  of  the  cornea,  and 
subsequent  opacities  leading  to  partial  or  complete  loss  of  vision. 

Treatment. — Prior  to  the  introduction  of  prophylactic  measures 
by  Crede,  the  frequency  of  ophthalmia,  especially  in  hospital 
practice,  was  considerable.  Since  the  introduction  of  these 
measures,  it  is  a  comparatively  unknown  affection.  In  hospital 
practice,  careful  prophylaxis  should  be  adopted  as  a  routine 
measure,  and  in  private  practice  also  when  there  is  any  reason  to 
suspect  the  presence  of  gonorrhceal  infection  in  the  mother.  It 
consists  in  first  carefully  wiping  all  discharge  away  from  the  eyes 
the  moment  the  head  is  born,  then  washing  them  gently  with  a 
little  warm  water,  and  finally  dropping  into  each  eye  one  or  two 
drops  of  a  one  per  cent,  solution  of  nitrate  of  silver.  A  twenty  per 
cent,  solution  of  argyrol  may  be  substituted  for  nitrate  of  silver, 
as  its  germicidal  action  is  as  strong  and  it  is  less  irritating.  If 
infection  occurs,  the  lids  must  be  separated  as  often  as  is  necessary 
to  prevent  the  accumulation  of  pus  between  them,  and  the  eyes 
washed  out  with  warm  water  or  with  boracic  lotion.  It  may  be 
necessary  to  do  this  in  the  acute  stage  at  intervals  of  an  hour,  or 
even  oftener.  Also,  once  a  day,  a  two  per  cent,  solution  of  nitrate 
of  silver  must  be  dropped  into  the  eyes,  and  they  must  be  kept 
bandaged.  All  contaminated  dressings  must  be  carefully  burnt 
to  prevent  the  spread  of  infection,  and  the  mother  should  be 
warned  of  the  dangerous  nature  of  the  discharge.  If  only  one 
eye  is  infected,  the  greatest  care  must  be  exercised  to  prevent  the 
extension  of  the  infection  to  the  other  eye,  and  the  latter  should 
be  covered  by  a  carefully  applied  hermetic  bandage. 

Umbilical  Infection.— The  umbilical  wound  may  readily 
become  the  seat  of  pyogenic  infection,  either  before  or  subsequent 
to  the  separation  of  the  funis.     In  such  cases,  the  infection  may 

70 — 2 


uo8  THE  INFANT 

remain  local  and  give  rise  to  an  omphalitis — i.e.,  an  inflammation 
of  the  cellular  tissue  and  skin  about  the  umbilicus ;  it  may 
involve  the  walls  of  the  umbilical  vessels  and  extend  to  the  liver, 
causing  an  acute  hepatitis  or  phlebitis  of  the  branches  of  the 
portal  vein  ;  it  may  extend  into  the  peritoneal  cavity,  giving  rise 
to  peritonitis  ;  or,  it  may  be  the  starting-point  of  a  general 
pyaemia. 

Treatment. — The  treatment  of  omphalitis  consists  at  first  in  the 
application  of  hot  antiseptic  compresses.  Later,  if  abscesses 
form,  they  must  be  immediately  evacuated.  The  strength  of  the 
infant  must  be  carefully  maintained,  and  the  administration  of 
stimulants  will  usually  be  required.  Haemorrhage  from  the 
ulcerated  umbilical  vessels  is  most  difficult  to  check,  as  any 
methods  of  compression,  which  may  temporarily  check  the 
bleeding,  will,  as  a  rule,  lead  to  fresh  sloughing,  and  so  to 
a  return  of  the  haemorrhage.  This  remark  also  applies  to  the 
use  of  perchloride  of  iron.  If  the  bleeding  is  slight,  a  folded 
pad  of  iodoform  or  sterilised  gauze  is  pressed  against  the 
bleeding-point.  The  skin  at  each  side  of  the  umbilicus  is  then 
drawn  in  a  fold  over  this  pad,  and  held  there  by  firmly- 
applied  strips  of  adhesive  strapping.  If  this  fails  to  check  the 
haemorrhage,  the  best  prospect  of  success  is  offered  by  nipping 
up  the  abdominal  wall,  and  passing  a  long  needle  from  side  to 
side  beneath  the  vessels ;  against  this  needle  they  can  be  com- 
pressed by  a  figure-of-eight  ligature  passed  tightly  round  its 
projecting  ends.  The  use  of  plaster  of  Paris  as  a  method  of 
plugging  the  umbilical  fossa  has  occasionally  been  found  suc- 
cessful. 

Prognosis. — The  prognosis  in  these  cases  is  bad  even  when  the 
infection  remains  local,  and  when  it  becomes  generalised  it  is 
almost  hopeless. 

The  appearances  of  the  abdominal  wall,  when  omphalitis  is 
present,  are  similar  to  those  of  cellulitis  elsewhere,  and  consist  at 
first  of  redness,  swelling,  and  induration  around  the  umbilicus. 
Later,  abscesses  form  in  the  cellular  tissue.  These  may  discharge 
externally  and  the  infection  wear  itself  out,  or  extensive  sloughing 
may  occur  leading  to  the  formation  of  a  large  ulcer.  During  this 
process,  the  umbilical  vessels  may  be  re-opened,  and  haemorrhage 
occur. 

Mastitis. — A  slight  amount  of  secretion  resembling  milk  is 
often  found  in  the  breasts  of  newly-born  infants  of  both  sexes. 
De  Sinety  has  shown  that  the  mammary  gland  of  the  newly- 
born  contains  spaces  lined  with  secreting  cells,  which  resemble 
those  found  in  the  adult.  If  the  breast  is  not  irritated,  this 
secretion  usually  ceases  in  a  week  or  ten  days.  Occasionally, 
however,  in  consequence  of  want  of  cleanliness,  or  of  injury 
produced  by  attempts  on  the  part  of  the  nurse  to  express 
the  secretion,  infection  occurs,  and  mastitis  results.     This  may 


TRAUMATA  DURING  BIRTH  1109 

get  well  in  a  day  or  two,  or  may  result  in  the  formation  of 
a  mammary  abscess.  The  diagnosis  of  the  latter  condition  is 
easy. 

Treatment. — If  the  infection  is  slight  and  pus  has  not  formed, 
the  application  of  a  hot  antiseptic  compress  is  usually  sufficient. 
If  pus  forms,  a  small  incision  must  be  made,  the  pus  evacuated, 
and  the  opening  kept  patent  for  a  day  or  two  by  means  of  a  small 
plug  of  iodoform  gauze.  As  a  rule,  the  condition  rapidly  gets 
well. 


TRAUMATA  DURING  BIRTH 

The  various  traumata  which  may  occur  during  birth  can  be 
divided  into  three  groups  : — Fractures,  Haemorrhages,  and  Nerve 
Lesions. 

Fractures. — Fractures  of  the  limbs  or  clavicles  are  of  occa- 
sional occurrence  during  the  operative  delivery  of  the  infant. 
Fracture  of  the  clavicle  or  humerus  is  especially  prone  to  occur 
during  attempts  at  bringing  down  the  arms,  when  extended  beside 
or  behind  the  after-coming  head.  Fracture  of  the  femur  is  more 
rare,  but  may  occur  during  the  extraction  of  an  impacted  breech. 
Fractures  of  the  bones  of  the  skull  are  of  still  rarer  occurrence. 
They  can  occur  in  consequence  of  the  force  by  which  the  head 
is  compressed  between  the  contracting  uterus  and  the  pelvic 
brim  in  cases  of  pelvic  contraction,  or  they  may  be  the  result  of 
delivery  by  the  forceps  or  of  the  forcible  extraction  of  the  after- 
coming  head. 

Treatment. — Fractures  of  the  clavicle  unite  readily,  and  all  that 
is  required  is  to  keep  the  upper  arm  bandaged  to  the  side  of  the 
chest.  Fractures  of  the  humerus  may  be  similarly  treated,  the 
lower  arm  also  being  fixed,  or  small  splints  may  be  applied  to  the 
sides  of  the  fractured  bone.  In  fractures  of  the  femur,  the  leg 
may  be  fixed  rigidly  by  means  of  an  extemporised  long  splint,  or 
as  Crede  recommends,  the  limb  may  be  maintained  in  a  position 
of  complete  flexion  alongside  the  body,  by  means  of  a  bandage 
round  the  body  and  the  popliteal  space.  It  should  be  kept 
in  this  position  for  about  fifteen  days.  This  method  has  the 
advantage  of  saving  the  constant  removal  of  soiled  bandages. 
Fractures  of  the  skull  are  usually  depressed.  If  caused  by  the 
pelvic  brim,  they  are,  as  a  rule,  situated  on  the  posterior  parietal 
bone.  Any  of  the  cranial  bones  may  be  broken  by  the  forceps. 
If  intra-cranial  haemorrhage  does  not  occur,  the  prognosis  is  good. 
No  special  treatment  is  required,  save  under  the  rarest  circum- 
stances, as  for  instance  where  a  depressed  fracture  is  associated 
with  symptoms  of  compression  of  the  brain. 

Hemorrhages. — The  important  haemorrhages,  which  result 
from  traumata  during  labour,  occur  in  the  form  of  haematomata, 


mo  THE  INFANT 

and  not  as  free  or  external  haemorrhage.  The  two  chief  seats  of 
such  hgematomata  are  beneath  the  pericranium,  and  in  the  sub- 
stance of  the  sterno- mastoid  muscle. 

Cephalhematoma. — -A  cephalhematoma  is  the  term  applied  to 
.a  blood  tumour  which  forms  beneath  the  periosteum  of  the 
cranial  bones,  as  the  result  of  the  rupture  during  labour  of  a 
small  vessel  in  this  situation.  As  a  rule,  it  is  single,  and  is 
found  over  the  presenting  bone,  but  cases  of  two  or  even  three 
distinct  haematomata  have  been  recorded,  each  situated  over  a 
different  bone.    In  the  case  shown  in  Fig.  467,  a  large  haematoma 


Fig.  467. — A  Double  Cephalhematoma. 
(From  a  photograph  of  an  infant  born  in  Dr.  Steevens'  Hospital.) 


formed  over  each  parietal  bone  after  a  normal  labour.  Cephal- 
haematoma  is  a  rare  condition.  It  occurs  in  both  normal  and 
difficult  labours,  and  while  its  occurrence  is  probably  favoured 
by  delay  or  by  traumata,  it  may  also  occur  apparently  quite 
independently  of  these  conditions.  In  such  cases,  it  may  be  due 
to  increased  blood  pressure,  to  changes  in  the  external  table  of 
the  cranial  bones,  or  to  an  altered  condition  of  the  blood. 

The  appearance  of  a  cephalhaematoma  is  at  first  very  much 
the  same  as  that  of  a  caput  succedaneum,  save  that  the  edges  of 


TRAUMATA   DURING  BIRTH  mi 

the  swelling  are  more  clearly  outlined.  On  closer  examination, 
these  edges  are  found  to  be  co-terminous  with  the  bone  over 
which  the  tumour  is  situated,  and  this  limitation  is  more  notice- 
able after  a  few  days  than  it  is  at  birth,  in  consequence  of  the 
gradual  disappearance  of  the  accompanying  caput  succedaneum. 
At  first,  the  haematoma  consists  of  a  tense  swelling  in  which 
fluctuation  can  be  obtained.  Later,  as  the  blood  coagulates,  the 
periphery  of  the  swelling  becomes  of  bony  hardness,  while  the 
centre  is  depressed  and  soft.  In  some  cases,  a  crackling  sensation 
is  experienced,  due  perhaps  to  the  formation  of  minute  bony 
plates  on  the  inner  surface  of  the  periosteum  (Holt).  Later  still, 
the  peripheral  hardness  extends  centripetally,  until  the  entire 
swelling  becomes  hard.  At  the  same  time  it  gradually  lessens 
in  size,  and  finally  disappears.  In  the  case  shown  in  Fig.  467, 
in  which  the  haematomata  were  of  large  size,  the  swellings  did  not 
commence  to  diminish  notably  in  size  until  the  third  week  after 
birth.  They  had  almost  completely  disappeared  by  the  sixth 
week.  Suppuration  seldom  occurs,  and,  when  it  does,  abrasions 
of  the  skin  over  the  swelling  are  usually  present,  and  through 
these  infection  has  occurred.  No  treatment  is  required  unless 
suppuration  occurs,  as,  if  left  alone,  the  blood  will  be  gradually 
absorbed.  If  suppuration  occurs,  the  resultant  abscess  must  be 
opened  and  drained. 

Hsematoma  of  the  Sterno-mastoid. — Haematoma  of  the  sterno- 
mastoid  is  a  condition  which  is  of  interest  from  its  rarity,  but  is  of 
no  great  clinical  importance.  The  traumatism,  to  which  it  is  due, 
occurs  during  birth,  but  the  existence  of  the  haematoma  is  usually 
not  recognised  until  ten  days  or  more  afterwards,  that  is,  until 
the  coagulated  blood  is  firm  enough  to  cause  a  distinct  tumour. 
It  usually  occurs  in  association  with  pelvic  presentation,  but  may 
also  be  found  after  forceps  application  in  head  presentation,  and 
is  said  to  be  due  to  over-twisting  of  the  head  producing  a  lacera- 
tion of  a  bloodvessel  in  the  muscle,  and,  in  some  cases,  laceration 
of  the  muscle  fibres  themselves.  The  tumour  is  usually  about  the 
size  and  shape  of  a  pigeon's  egg,  and  resembles  an  enlarged 
lymphatic  gland.  It  is  movable,  hard,  and  obviously  situated  in 
the  belly  of  the  muscle.  If  it  is  of  a  very  large  size,  and  asso- 
ciated with  an  extensive  laceration  of  the  muscle  fibres,  it  may 
possibly  give  rise  to  a  subsequent  torticollis.  The  condition  calls 
for  no  special  treatment,  though  gentle  massage  may  promote  the 
absorption  of  the  blood. 

Nerve  Lesioxs. — The  nerve  lesions  which  result  from  injuries 
during  birth  may  be  divided  into  two  groups : — central  lesions 
and  peripheral  lesions. 

Central  Lesions. — Central  lesions  are  much  more  serious  than 
are  peripheral  lesions  and  are  also  rarer.  They  usually  occur  as 
meningeal  haemorrhages,  either  localised  or  spread  over  the  entire 
surface  of  the  brain,  as  a  result  of  which  partial  or  complete  hemi- 


1 1 12  THE  INFANT 

plegia  is  found.  Convulsions  also  are  common,  and  so  are  dis- 
turbances of  the  respiratory  and  cardiac  functions.  Death,  as  a 
rule,  results  within  the  first  four  or  five  days,  but  in  some  cases 
may  not  occur  for  weeks,  months,  or  even  years.  Treatment  is 
of  little  avail. 

Peripheral  Lesions. — Peripheral  nerve  lesions  are  considerably 
more  common  than  are  central  lesions,  and  are  of  interest  from 
the  point  of  view  of  the  prognosis.  The  most  common  lesions 
are  those  of  the  facial  nerve,  and  of  the  upper  trunks  of 
the  brachial  plexus.  Facial  paralysis  is  of  not  uncommon 
occurrence  after  delivery  by  the  forceps,  in  consequence  of  the 
compression  of  the  facial  nerve  at  the  point  of  emergence  from 
the  cranial  cavity.  The  paralysis  is,  as  a  rule,  unilateral,  and 
may  be  noticed  an  hour  or  so  after  the  infant  is  born,  or  not 
for  a  day  or  two.  When  the  infant  is  asleep,  the  eye  on  the 
affected  side  is  open,  in  consequence  of  the  paralysis  of  the 
orbicularis  palpebrarum  muscle.  This  contrasts  with  the  appear- 
ance of  the  infant  in  facial  paralysis  of  central  origin,  in  which 
the  orbicularis  muscle  usually  escapes.  When  the  infant  cries, 
the  unaffected  side  of  the  face  puckers  up,  while  the  paralysed 
side  remains  smooth,  and  the  mouth  is  drawn  to  the  unaffected 
side.  As  a  rule,  the  condition  disappears  in  a  day  or  two,  or,  in 
some  cases,  may  last  for  a  few  weeks.  Occasionally,  the  lesion 
may  be  more  severe,  and  the  reaction  of  degeneration  be  present. 
In  such  cases,  the  regular  use  of  the  galvanic  current  will  be 
necessary.  The  eye  on  the  paralysed  side  must  be  watched, 
and  care  taken  that  it  does  not  suffer  from  the  exposure  which 
results  from  paralysis  of  the  lid. 

Paralysis  of  the  upper  extremity,  as  described  by  Erb,  is  usually 
the  result  of  lesions  of  the  fifth  and  sixth  cervical  nerves,  and  so 
is  confined  to  a  certain  group  of  muscles.  These  are  the  deltoid, 
the  biceps,  the  supinator  longus,  the  brachialis  anticus,  and 
sometimes  the  supra-  and  infra-spinatus.  The  cause  of  the  lesion 
is  probably  to  be  found  in  undue  traction  on  the  nerves  on  one 
side  in  consequence  of  the  head  being  drawn  over  too  far  towards 
the  opposite  shoulder  (Fieux*),  as  may  occur  during  traction  on 
the  head  with  the  forceps,  or  with  the  hand  when  delivering  the 
shoulders,  or  when  bringing  down  arms  extended  beside  the 
after-coming  head.  Erb,  on  the  other  hand,  after  whom  this 
form  of  paralysis  is  usually  named,  considers  that  it  is  due  to 
pressure  exercised  by  the  ringers  or  forceps  on  '  Erb's  spot ' — a 
point  on  the  neck  at  which  electrical  stimulation  causes  the 
contraction  of  all  the  muscles  usually  involved  in  Erb's  paralysis. 
In  consequence  of  the  paralysis,  the  arm  hangs  lifelessly  by  the 
side.  It  is  rotated  inwards,  the  forearm  pronated,  and  the  palm 
looking  outwards.     In  severe  cases,  the  reaction  of  degeneration 

*  '  De  la  Pathogenie  des  Paralysies  brachiales  chez  le  Nouveau-ne,'  Ann. 
de  Gynec,  January,  1897. 


TRAUMATA  DURING  BIRTH  1113 

is  present.  The  majority  of  cases  recover  within  two  or  three 
months,  the  improvement  commencing  in  the  biceps  and  ending 
in  the  deltoid.  According  to  Holt,  spontaneous  recovery  is 
not  to  be  looked  for  unless  it  occurs  within  this  time.  In 
severe  cases,  permanent  paralysis  may  result.  The  treatment 
of  Erb's  paralysis  consists  in  the  regular  and  persistent  use  of 
the  galvanic  current,  or  of  the  faradic  current  if  the  muscles 
react  to  it. 


INDEX 


Abdomen  in  unduly  prolonged  labour, 
294 
pendulous,  328,  541,  726,  743,  750, 

826 
signs  of  pregnancy  in,  228-230,  233 
Abdominal    palpation,    164-173,     828, 
1009-1011 
complications      determined       by, 

172-173 
diagnosis  of  brow  presentation  by, 
390 
of  double  monsters,  856-857 
of  face  presentation,  367-369 
of  hydrocephalus,  844 
of  multiple  pregnancy,  814-815 
of  myomata,  794 
of  pelvic  contraction,  724 
of  pelvic  presentation,  407-408 
of  placenta  praevia,  697 
of  pregnancy,  165-166 
of  shoulder  presentation,  431- 

432 
of  twin  pregnancies,  820 
of  vertex  presentation,  306-307 
first,  or  fundal  grip,  166-168 
second,  or  umbilical  grip,  168-169 
third,  Pawlic's,  or  first  pelvic  grip, 

169-171,  172 
fourth,  or  second  pelvic  grip,  171- 

172 
in  secondary  uterine  inertia,  714 
various  authors  on,  164 
Abdominal    wall,    changes    in,    during 
pregnancy,  216-217 
change  in,  in  third  stage  of  labour, 

293 
during  puerperium,  453 
laxity  of  for  external  version,  418 
in  nulliparity  and  parity,  236-237 
in  omphalitis,  1108 
Abdomino-vaginal    examination,     174, 

179-182 
Abegg,   statistics  of  prolapse  of  cord, 

S29 
Abortion,  243,  247,  248,  253,  482.  485, 
503.  530-531,  621-632 


Abortion  in  acute  and  chronic  decidual 
endometritis,  480,  481 
in  acute  yellow  atrophy  of  liver, 

576-577 
aetiology  of,  622  623 
backward  displacements  of  uterus 

a  cause  of,  484 
cervical,  629 

diagnosis  of.  629 

symptoms,  629,  677 

treatment,  629 
complete,  631-632 

diagnosis,  631 

symptom-,  631,  678 

treatment,  632 
fibro-myomata  a  cause  of,  791 
frequency  of,  621 
from  cardiac  disease,  588-589 
from  diabetes  in  pregnancy,  581 
from  malignant  disease  of  vagina 

or  cervix,  704 
from  procidentia,  543 
from  traumatism,  704-705 
haemorrhages  in,  673 
incomplete,  630-631 

diagnosis,  630 

symptoms,  630,  677 

treatment,  630-631 
induction  of,  966-967 
in  pneumonia,  565 
in  relapsing  fever,  56 
in  scarlatina,  566 
in  syphilis,  571 
missed,  618,  632.  674 

diagnosis,  632 

symptoms,  632,  678 

treatment,  632 
tetanus  after,  910 
threatened,  624-629 

menstruation  in   pregnancy  a 
sign  of,  703-704 

symptoms,  624-625,  677 

treatment,  626-629 
tubal,  657-658 
varieties,  623-632 
Abscess  in  extra-uterine  pregnancy,  640 
15 


1 1 16 


INDEX 


Abscess,    formation   of,    on    death    of 
foetus,  646-647 
mammary,  treatment,  947-948 
Accessory  muscles   of  labour,  contrac- 
tions of,  263 
Accouchement  force,  686.  691,  955,  956 

in  placenta  previa,  7ocS  7°2 
Acephalians,  850 
Acetone  in  puerperal  urine  and   prior 

to  delivery.  452 
Adrenalin,  use  of,  in  uterine  inversion, 

897 
Ahlfeld  on  funic  souffle,  187 

on  rupture  of  pelvic  articulations, 
894 
Aichel  on  production  of  vesicular  mole 

in  dogs,  490 
Air-hunger,  663,  870 
Albert,    cases    of    placental    tumours, 

520-521 
Albuminuria  and  eclampsia,  601 
in  pregnancy,  567,  582 
in  puerperal  insanity,  943 
Albuminuric  placenta,  524 
Alimentary  system,    infantile,   diseases 

of,  1 102- 1 106 
Allantois,  formation  of,  81-83 
Amenorrhcea,  225,  234,  235 

in  extra-uterine  pregnancy,  660 
Amnio-chorionic  pouch,  275 
Amnion,  formation  of,  78-81,  104-105 
Amniotic  hydrorrhcea,   275,    485,  486- 

487 
Ampulla  of  Fallopian  tube,  51 
Anaemia  during  pregnancy,  476,  477 
maternal,  a  cause  of  intra-uterine 
death  of  foetus,  616 
Anaesthetics      for      operations     during 
pregnancy,  248 
in  labour,  357-359 
Anencephalians,  851 
Anidians,  850 
Ankylosis    of    the    sacrum    and    ilium, 

765-766,  771 
Anning,  ovarian  pregnancy,  637 
Anteflexion  of  uterus,  539-541 
Anterior  asynclitism,  313,  328-331,  756 
Anterior  development  of  uterus,   537- 

538 
Anteversion  of  uterus,  541-543 
Antisepsis,  introduction  of,  139-141 

necessity  of,  141 
Anti-streptococcic  serum,  934,  936,  937 
Anus,  fcetal,  408 
Aortic  pulse,  maternal,  184 
Aortic  regurgitation  in  pregnancy,  593 
Aperients  during  puerperium,  458 
Areola,     mammary,     appearance     of, 
during  pregnancy,  219-220 
secondary,  220 
umbilical,  217 


Armamentarium,  obstetrical,  I55-I6i 
antiseptics,  155- 156 
drugs,  156-157 
instruments,  i57_I6i 
Arsenic-poisoning,    maternal,  cause    of 

intra-uterine  death  of  fcetus,  617 
Arthritis  deformans,  772 
Ascites  as  cause  of  abdominal  enlarge- 
ment, 236 
fcetal,  847-848 
Asepsis,  introduction  of,  139 
Asphyxia,  fcetal.  in  pelvic  presentation, 
419,  422 
maternal,  as  cause   of  precipitate 
labour,  710 
Asphyxia  neonatorum,  aetiology.  1097 

treatment,  1097-1102 
Atmocausis  in  tuberculosis,  564 
Atresia  of  cervix,  805-807 
Atthill,    Lombe,    effect    of    ergot    on 
uterus,  359 
on  treatment  of  threatened  abor- 
tion, 626 
on  use   of    ergot   and    strychnine 
during  pregnancy,  486 
Auscultation,  335,  339 

diagnosis   of  brow   presentations, 

392  .      . 

of  face  presentation,  370 
of  multiple  pregnancy,  815 
of  pelvic  presentation,  410 
of  shoulder  presentation,  433 
of  vertex  presentation  by,  309 
of  fcetal  heart,  185-188 
of  the  uterus,  182-188 

methods  of,  183 
diagnosis  of  presentation  or  pro- 
lapse of  cord  by,  833 
relative  advantages  and  possibili- 
ties of,  188-189 
Autosites,  850-852 

double,  853-854,  855 
Auvard      on      Bouchard's     theory     of 

eclampsia,  604 
Axillae,  lumps  in  skin  of,  453 

Bacillus  aerogenes  capsulatus  in  puer- 
peral fever,  910 
Bacillus  coli  in  puerperal  fever,   907, 
908-910 
in  septic  endometritis,  923 
Bacillus  of  tetanus  in  puerperal  fever, 

910 
Bacteria  in  genital  canal,  142-148,  459 
Bacterial  theory  of  eclampsia,  602 
Bailly  on  uterine  souffle  after  death  of 

fcetus,  184 
Ball-valve  action  of  head,  177,  270 
Ballantyne      on      anaesthetics      during 
pregnancy,  248 
on  cleidotomy,  1074 


INDEX 


1 1 17 


Ballantyne    on    cystic    degeneration    of 
foetal  kidneys,  84S 
on    effect  of  maternal  anesthesia, 

359 

on  foetal  oedema  and  ascites,  847 

on        hydramnios        and        oligo- 
hydramnios, 506-507,  510 

on  hydrocephalus,  844 

on  immunity  of  infants  to  small- 
pox infection,  570 

on  cedema  of  the  placenta,  521 

on  syphilis  in  placenta,  513,  514 

on     management     of     pregnancy, 
245-246 
Ballottement,  307,  408,  493 

external,  166 

internal,  182,  661 
Bandl,  ring  of,  213-214,  26S 

on  shortening  of  cervix  uteri,  212- 
214 
Bar,  clamping  of  the  funis,  1081 

statistics    of   mortality    after   sym- 
physiotomy, 1059 

onset  of  eclampsia,  605-606 
Barbour  on  detachment  and  expulsion 
of  placenta,  281 

on      junction      between      uterine 
segments,  26S 
Barker  on  albuminuria   in    pregnancy. 
582 

Fordyce,  on  puerperal  fevers,  902 
Barnes      on      abnormal      position      of 
placenta,  518 

on  chorea  during  pregnancy,  577, 
578 

on  expulsion  of  placenta  by  manual 
compression,  353 

on  internal  version,  1012 

on    treatment   of    atonic    haemor- 
rhage, 866 

on  treatment  of  incarcerated  uterus, 
535-536 

on   treatment  of  pelvic    presenta- 
tion, 1028,  1030 

on   treatment  of  placenta  praevia, 
700-701 

on  use  of  catheter  in  retention  of 
urine,  474 
Bastard  on  effect  on  cord  of  bathing 

infant,  1083 
Baths  during  pregnancy,  246 
Baudelocque's  method  in  brow  presen- 
tations, 394 

in    face    presentations,    384  -  386, 
387 
Baudelocque    Clinique,    mortality   sta- 
tistics of  infants   during  labour 
and  after  birth,  299 

statistics  of  face  presentations,  361 

statistics     of    foetal     mortality    in 
pelvic  presentations,  423 


Baudelocque      Clinique,     statistics     of 
micturition    during   puerperium. 

454. 
statistics  of  miscarriage,  633 
statistics    of    pelvic    presentations, 

402-403,  404 
statistics   of  posterior   rotation   of 
occiput,  325 
Beale  on  urine  in  chorea,  579 
Bennewitz    on    diabetes    during    preg- 
nancy, 581 
Bernard  on  carbonate  of  ammonium  in 

eclampsia,  602 
Bertillon   on    frequency   of   twin   preg- 
nancies. 808 
Bichat  on  puerperal  fever,  905 
Bi-polar  version,  see  lender  Version 
Birth  corpore  conduplicato,  435-436 
Bischoff  on  fertilisation  of  ovum,  642 
Blacker,  maternal  mortality  in  placenta 

praevia,  702 
Bladder,  anatomy  of,  58 

changes  in,  during  labour,  272 

during  pregnancy,  217 
foetal,  103-104 
full,  effect  on  uterus,  447 
inflammation     of     {see     Cystitis), 

926-927 
in  incarceration  of  uterus,  532 
irritability  during  pregnancy,  474- 

475 
management  of  during  puerperium, 

454,  457-458 
overfull,  and  pregnancy,  235 
overdistended,    and    retention    of 

urine,  473-474 
as     cause     of    secondary    uterine 
inertia,  715 
Bland-Sutton  on  normal  site  of  fertilisa- 
tion, 641 
on  periodicity  of  menstruation,  256 
on    primary   intra-peritoneal   rup- 
ture, 656 
on  tubal  moles,  646 
Blood,    composition   of,    during    puer- 
perium, 450 
during  pregnancy,  221-222 
Blood-mole,  616 

Bloodvessels    of    uterus,    changes    in, 
during  involution  of  uterus,  444 
during  pregnancy,  208 
Blot,  on  galactosuria,  580 
Blumer  on  puerperal  fever,  910 
Bonnaire  on  cleidotomy,  1074 
Bonney  on  Bacillus  coli   in  puerperal 
fever,  908 
on     Diplococcus     pneumoniae     in 
puerperal  fever,  910 
Bonte  on  milky  or  puriform  lochia,  905 
Borborygmi  [see  Intestinal  sounds),  184- 
185 


iii8 


INDEX 


Borner    on    weight     of    uterus     after 

delivery,  446 
Bossi's  dilator  in  eclampsia,   61.I,  612, 
613 
use  of,  612 
Boston  Lying-in  Hospital,  statistics  of 

placenta  praevia,  692 
Bouchard    on    injection    of    urea    for 
eclampsia,  602 
on  secretion  of  placenta,  95 
theory  of  eclampsia  of,  604 
on  urineemic  theory  of  eclampsia, 
603 
Bouillaud  on  uterine  souffle,  184 
Bowels,  action  during  pregnancy,  246 
Brain,  condition  of,  in  eclampsia,  500 
Breasts,  in  death  of  foetus,  243 

care  of.  during  pregnancy,  248-249 
changes     in,     during     pregnancy, 
218-221,  227-228,  233 
during  puerperium,  448-449 
in  nulliparity  and  parity,  236 
treatment  of,  during  lactation,  463- 
464 
Breech    presentation,     see    tender  Pre- 
sentation 
Bregma,  or  anterior  fontanelle,  1 1 1 
Breisky  on  external  pelvimetry,  193 
Bright's  disease,  see  Nephritis 
Brion  on  statistics  of  abnormal  presen- 
tations in  miscarriage,  633 
Bronchitis,    danger    of,    during    preg- 
nancy, 562 
as  cause  of  precipitate  labour,  710 
Brown-Sequard,    contractions    of    the 

uterus  in  animals,  256 
Budin  on  ligation  of  cord,  1082 
after  birth,  1080 
maximum  diameter  of,  114 
on  position  of  chin  in  face  presen- 
tation, 368 
Buhl  on  weight  of  viscera  of  foetus,  109 
Buist  on  mortality  from  chorea  during 

pregnancy,  578 
Bumm  on  puerperal  fever,  901 
on  local  septic  infection, 
on  treatment  for  eclampsia,   611, 
612 
Busch  on  cephalic  version,  1010 
Byers  on  puerperal  mortality,  901 

Caesarean  section,  1036-1038, 1054-1055 
after-treatment,  1048 
assistants,  1041 
in  cancer  of  the  uterus,  799 
in  cases  of  ovarian  tumours,  801, 

802,  804 
complete  hysterectomy,  1048 
indication  for,  1038-1040 
for  myema  of  the  uterus,  797,  798 
partial  hysterectomy,  1047- 1048 


Caesarean     section,     Porro- Caesarean, 
1047 
preparation  of  patient,  1046 
prognosis,  1048- 1049 
radical  operation,  1046-1049 
for  stenosis  of  vagina  or  vulva,  807 
time  for  operation,  1040- 1041 
in  tumours  of  vagina  and  vulva, 
805 
Calcareous    degeneration   of    placenta, 

522 
Cameron,      Murdoch,     on      Caesarean 

section,  1043 
Cancer  of  uterus,  798 
diagnosis,  798 
effect  upon  labour,  798 
prognosis,  799-800 
treatment,  798-799 
Caput  succedaneum,  178,  379,  398,417. 
728 
in  reversed  rotation  of  head,  379 
in   posterior    fontanelle    presenta- 
tion, 398 
in  contracted  pelvis,  728 
Carbon  dioxide  poisoning,  617 
Carbon  monoxide  poisoning,  617 
Cardiac  sounds,  fetal,  185-187 

maternal,  184 
Cardiac  syncope  after  haemorrhage,  874 
Carunculae  myrtiformes,  36 
Caseinogen,  448 
Caul,  the,  276 

Cephalhaematoma,  infantile,  1110-1111 
Cephalic  version,  see  under  Version 
Cephalopagous  monsters,  856 
Cervix  uteri,  39,  42,  47,  257,  260,  261, 
290 
ante-partum  haemorrhage  from,  704 
artificial  dilatation  of,  by  incision, 
956 
indications,  957 
instrumental,  958 

after-treatment,  958 
operation,  957 
bacteriology  of,  146-148 
cancer  of  {see  under  Uterus),  798 
changes     in,     during     pregnancy, 
211-215 
in  premonitory  stage  of  labour, 
286 
condition     of,    in    case    of    ante- 
partum haemorrhage,  676 
contraction   of,    see    Uterine    con- 
tractions 
dilatation  of,   254-255,   275,    287, 

.339  . 

dimensions,  43 
hypertrophy  of,  544-546 
inflammation  of,  551-552 
lacerations  of,  889 
aetiology,  889 


INDEX 


1119 


Cervix    uteri,    lacerations   of,    degrees, 
889 
diagnosis,  889-890 
symptoms,  889 
treatment,  890 
malignant  diseases  of,  704 
in  nulliparity  and  parity,  239 
in  tubal  pregnancy,  648 
shape  of,  in  cervical  abortion,  629 
stenosis  and  atresia  of,  S05-807 
etiology,  805-806 
diagnosis,  806 
effect  on  labour,  806 
treatment,  806-807 
taking   up  of,   258,   264-267,    268, 

287 
see  also  Uterus 
Chamberlen,  Hugh,  982 

Peter,  982 
Champetier  de  Ribes'   bag,  699,  700, 

701,  702 
Champneys  on  lumps  in  skin  of  axilla?, 

453  .  . 
on  position  of  foetus  in  kyphotic 
pelvis,  775 
Chantemesse   on   tetanus  in  childbed, 

910 
Charpentier    on    chorea    during   preg- 
nancy, 577 
Chloride  of  zinc  in  uterine  cancer,  799 
Cholera,  480 

Chorea  during  pregnancy,  577-580 
Chorion,  formation  of,  80-81 
rupture  of,  275 
syphilis  of,  512,  513 
vesicular  degeneration  of,  488,  489, 
490,493,  617 
Chorion-epithelioma,  493,  497,  870 
diagnosis,  503-504 
origin  of,  497-500 
pathological  anatomy,  500-503 
prognosis,  504-505 
symptoms,  503 
treatment,  504 
Chrobak  on  chorion-epithelioma,  505 
Churchill  on  coiling  of  cord,  525 

on    frequency   of    multiple    preg- 
nancy, 808 
on   frequency  of  vertex  presenta- 
tion, 300 
statistics  of  prolapse  of  cord,  829 
of  transverse  lies,  426 
Circulatory  system,  changes  in,  during 
pregnancy,  221-222 
during  puerperium,  449450 
Cleidotomy  843,  1074 
indications  for,  1074 
instrument,  1074 
operation,  1074- 1075 
Clinique  Baudelocque,  see  Baudelocque 
Hospital 


Clitoris,  30,  32-34 

Clonic  spasm,  716,  717 

Coccygeus  muscle,  62 

Coccyx,  5 

Cceliotomy   in    ruptured    uterus, 


S85, 


Coitus  during  pregnancy,  248 
Colles    on     infection     of    nurse    with 
syphilis  from  child,  573 
on     syphilis     during      pregnancy, 

571 
Collins  on  the  use  of  chloride  of  lime, 

141 

on  diagnosis  of  twins  by  ausculta- 
tion, 815 
on   frequency  of  vertex    presenta- 
tions, 300 
Colostrum,  448-449,  1087 
Colpeurynter,    use    of,    for    reposition 

of  incarcerated  uterus,  536 
Combined    version,    see    Bi-polar    and 

Combined,  under  Version 
Congenital    dislocation    of    the    hips, 

pelvis  of,  757-759 
Constipation    during    pregnancy,    246, 
471-472 
infantile,  1 102- 1 103 
a  predisposing  cause  of  puerperal 

fever,  912,  913 
prolonged,   a  cause  of  eclampsia, 
601 
Convulsions,  maternal,  see  Eclampsia 

infantile,  1104 
Cookman,  case  of  quintlets  recorded  by, 

809 
Cord,  see  Umbilical  cord 
Cork   Street   Fever   Hospital,   Dublin, 
mortality  from  enteric  in,  557 
mortality    from    small-pox    during 

pregnancy,  569,  570 
rarity   of    scarlatina    during    preg- 
nancy, 566 
Cormack  on  miscarriage  from  relapsing 

fever,  566 
Corpus  luteum,  56-57 
Cowper,  glands  of,  37 
Coze    on    Streptococcus    pyogenes    in 

puerperal  fever,  907 
Craiger    on     danger     from     scarlatina 

during  pregnancy,  568 
Craniotomy,  1060 
conditions,  1064 
extraction  of  head,  1068-1070 
indications  for,  1060-1061 
perforation  of  cranium,  1064-1067 
prognosis,  1070 
reduction  of  skull,  1068 
Crede,  expulsion  of  placenta,  352,  353, 
354 
on  abdominal  palpation,  164 
on  external  pelvimetry,  192 


INDEX 


Crede  on  internal  pelvimetry.  196 
on  ophthalmia  neonatorum,  1107 
statistics  of  prolapse  of  cord,  829 
treatment   of    ophthalmia    neona- 
torum, 1083 

Crepitatory  sounds  heard  over  uterus. 
185 

'Cross-birth,'  425 

Crural  phlebo-thrombosis,  938-940 
symptoms,  939 
treatment,  939 
varieties.  938 

Curetting.  965 

Curschmann   on    enteric   fever   during 
pregnancy,  557 

Cutler  on  pulse-rate  during  puerperium, 

45° 
on   respiratory  rate    during   puer- 
perium, 453 

Cycle cephalians.  851 

Cystitis.  926-927 

Cysts,  placental.  521 

Dakin    on    albuminuria    in    scarlatina 
during  pregnancy,  567-56S 
on  blood  loss  during  labour,  863 
on  decidua,  true  and  false,  676 
on  degeneration  of  uterine  muscle, 

879 
on   douching   during   puerperium. 

460 
on  fcetal  attitude,  122 
on  menstruation  during  pregnancy, 

modification  of  first  cardiac  sound 

by,  450 
presenting  head  and  lower  uterine 

segment,  270-271 
on    salivation   during    pregnancy, 

472 
on    scarlatina    during    pregnancy 
and  puerperium,  567 
De    Sine'ty    on     mammary    gland     of 

infants.  1108 
Dease  on  puerperal  fever,  905 
Death  of  mother  in  childbed,   causes, 

295-296 
Decapitation.  1070 

indications.  1070-1071 
operation,  1071-IC73 
Decidua,  275,  280 

changes  in,  during  puerperium.  443, 

444 
diseases  of,  as  cause  of  abortion, 

622 
false,  in  tubal  pregnane}-,  648,  667 
non-deciduate  classes  of  mammals, 

•;->4 
as  origin  of  chorion -epithelioma, 

497 
inflammation  of,  480-487 


Decidua,  ovum,  relation  to.  84-85 
refiexa,  87,  645 
serotina,  88 

in  syphilis,  514 
changes  in.  during  pregnancy.  255 
stratum  compactum.  85-87,  88 

spongiosum,  85-87,  88 
vera,  85-S7,  645 
and  vesicular  mole,  492-493 
Decidual  endometritis,  487,  875 
abortion  caused  by,  622,  623 
a       cause       of      detachment      of 

placenta,  683 
acute,  480 

chronic,  abortion  caused  by,  48 1 
aetiology,  484 
diagnosis,  485 

pathological  anatomy,  481-484 
prognosis,  486-487 
symptoms,  484-485 
treatment,  485-486 
and  vesicular  moles,  4S9 
syphilis  a  cause  of,  484 
use  of  strychnine  during.  486 
Deciduoma    malignum,    see    Chorion- 

epithehorna 
Delivery  in   cases    of    cancer    of   the 
uterus,  79S-799 
in  cases    of  uterine  rupture,   884, 

885 
connection  between  period  of,  and 

pelvic  presentations,  401-402 
immediate,  in  cases  of  prolapse  of 

cord,  837-838 
methods  of  ascertaining  date,  239- 

242 
premature,  in  multiple  pregnancy, 

818 
respiratory  rate  after,  453 
spontaneous,  statistics  of  occurrence 
in  anterior  and  posterior   posi- 
tions of  vertex,  327 
during   uterine   contractions,    343- 

344 
Dembo's  ganglia,  254 
Denman    on    conversion    of    shoulder 

into  pelvic  presentation,  434 
Depaul  on  auscultation  of  uterus,  183 
on  fcetal  cardiac  sounds,  185 
on  recurrence  of  molar  pregnancies, 

489 
statistics  of  twin  presentations,  S13 
Descemet  on  symphysiotomy,  1050 
Dessaignes,  Ribemont-,  see  Ribemont- 

Dessaignes 
Deutoplasm,  70 

Diabetes,    maternal,    cause    of    fcetal 
death,  617 
mellitus  in  pregnancy,  5S0-582 
Diaphragm,  290 

pelvic,  62-63,  290 


INDEX 


Diarrhoea,  infantile,  1103-1104 
•  I  iology,  1 104 
symptoms,  1104 
treatment,  1104-1 105 
Diaz,  Correa,  on  weight  of  placenta  and 

f< itus  in  syphilis,  513 
Dickinson    on    primary  amputation    of 

funis,  1081 
Die)  'luring  pregnancy,  246 
during  eclampsia,  608 
effect    on    composition    of    milk, 
1088- 1089 
Digestive    system,    during     pregnancy, 
222,  469-472 

during  puerperium,  452,  456,  457 
I  Hphtheria,  effect  on  pregnancy,  555-556 
of  vulva  and  vagina,  920 
bacillus,  in  puerperal  fever,  910 
Diplococcus   pneumoniae,  in  puerperal 

fever,  910 
Dirmoser   on  hyperemesis  gravidarum, 

596 
Dislocations,   pelvic  deformities    from, 

787-790 
Dobbin  on  'air  embolism,'  910 

on  typhoid    bacillus    in    puerperal 
fever,  909 
Doderlein's  aspirator  for  uterine  secre- 
tions, 933 
on  vaginal   bacteriology,   143,  144, 

145 
Dohrn    on    capacity   of    lungs   during 

pregnancy,  588 
Dolicho-cephalic  head,  366-367 
Douglas  (of  Dublin),  spontaneous  evo- 
lution first  described  by,  434 
pouch  of,  37,   179,  534,  535-  794, 
800,  801 
retro-uterine    hematocele    in, 

C'39 
tumours   in,    179.   534-5,   794, 
800,  801 
D'Outrepont  on  cephalic  version,  1010 
Dreschfeld     on    enteric    fever    during 
pregnancy,  557 

Dress  during  pregnancy,  247 

Drugs,  effect  on  milk,  1089 

I  >ubi   on  duration  of  labour,  289 

'Dublin     method'     for    expulsion    of 

placenta,  291,  353-354,  355,  866 
Dubois   on    frequency   of   triplet    preg- 
nancies, 808 
Duclos  on  decidual  hydrorrhoja,  484 
Diihrssen    on    anaemia   of  kidneys    in 
eclampsia,  598 
on  analysis  of  urine  in  eclampsia, 

601 
on  Cesarean  section,  538 
on  dilatation  of  os  by  deep  incisions 

in  eclampsia,  610,  61 1 
on  causation  of  eclampsia,  601 


Diihrssen  on  hypertrophy  of  cervix,  546 
on  intra-tubal  tumour,  643 
on  maternal  anesthesia,  359 
on    maternal    mortality  from    pla- 
centa previa,  702 
on  nephritis  in  pregnancy,  583 
on      prophylactic      treatment     of 

eclampsia,  608 
on  stenosis  of  cervix,  806 
on  site  of  fertilization,  642 
on   treatment  of  cancer  of  uterus 

during  labour,  799 
on  treatment  of  threatened  abor- 
tion, 628 
Dumas  on  albuminuria  in  pregnancy, 

582 
Duncan,  Matthews,  on  centre  of  gravity 
of  foetus,  127 
on  detachment   and   expulsion    of 

placenta,  280-281 
on  causation  of  face  presentation, 

365-366 
on  force  of  uterine  contractions,  262 
on  galactosuria,  580 
on  induction  of  premature  labour 

in  diabetics,  582 
on     intra-uterine  death   of  foetus, 

617 
on  length  of  foetus,  108 
on  lengthening  of  cervix  uteri,  212 
method     of     predicting     date     of 

delivery,  239 
on  movement  at  sacro-iliac  joint, 

25, 338 
term  'sapremia'  used  by,  903 
Durante    on   origin    of  chorion-epithe- 
lioma, 498 
Dyspnrea,  870 

Eberth  on  enteric  of  foetus,  558 
Ecchymosis  of  the  foetal  skin,  379,  417, 

743 
Eclampsia,  etiology  of,  601-605 
Cesarean  section  in,  1039 
complications  of,  608 
hyperemesis  gravidarum  and,  596 
intra-uterine  death  of  foetus  from, 

617 
in     pregnancy     and     puerperium, 

598-613 
nephritis  and,  582,  584-587 
neurotic  theory  of,  602 
prognosis,  613 
reflectorica,  602 

relative  rate  of  mortality  from,  613 
symptomatic  condition  rather  than 

specific  disease,  605 
symptoms,  actual,  606-607 

prodromal,  606 
time  of  onset,  605-606 
treatment,  curative,  608-613 

71 


INDEX 


Eclampsia,  treatment,  prophylactic,  608 

in  twin  pregnancies,  818 
Ectopia  vesica:,  790 
Ectromelians,  856 
Eden  on  placental  cysts,  521 

on  tuberculosis  of  the  placenta,  522 
Edgar  on  gonorrhceal  septic  infection, 

923 
Eisenhart  on  hernia  of  pregnant  uterus, 

546 
Embolism,  air,  possible  cause  of,  910 
pulmonary,  874,  949 
causes,  949 
symptoms,  949 
treatment,  949 
Embryo,  causes  of  death  of,  622-623 
epiblast,  74,  76,  78 
formation  of,  74-78 
mesoblast,  78 
Embryotomy,  1070 

decapitation,  1070- 1073 
evisceration,  1073- 1074 
in  case  of  double  monsters,  858 
in  case  of  excessive  size  of  fcetal 

shoulders,  843 
in  shoulder  presentation,  436,  437 
in    tumours   of   liver   and    spleen, 
849 
Emphysema  of  abdominal  wall,  crepi- 

tatory  sounds  produced  by,  185 
Encephalocele,  fcetal,  845-846 
Enchondroma,  787-788 
Endarteritis,  syphilitic  lesions  of  cord 

in,  514 
Endocarditis,  septic,  935 
Endocervicitis,  55 1-552 
prognosis,  551-552 
treatment,  551 
Endocymians,  854 
Endometritis,  catarrhal,  483,  487 
cause  of  fcetal  death,  616 
cause  of  subinvolution  of  uterus, 

.949 
diphtheritic,  910,  923 
enlargement  of  uterus  from,  234 
cause  of  placenta  prsevia,  692 
putrid,  913,  914 
septic,  920-925 
symptoms  of,  927-928 
Endometrium,  congestion   of,   a  cause 
of  secondary  post-partum  hsemor- 
rhage,  869 
and  lymphatic  sepsis,  931 
malignant     disease    of,    cause    of 

abortion,  622 
structure  of,  45,  46 
Engel,  statistics  of  frequency  of  vesi- 
cular mole,  488 
Enteric  fever  in  pregnancy,  557-559 
mortality  from  during,  557-558 
Epiblast,  structure  of,  74,  76,  78 


Epilepsy,  diagnosis  from  eclampsia,  607 
Episiotomy,  346,  807 
Erb  on  peripheral  lesions,  11 12 
Ergot,  in  uterine  inertia,  712 

as  cause  of  spasmodic  contraction, 
716 
of  placental  retention,  875 

in  atonic  haemorrhage,  866 

in  pyasmia,  936 

in  secondary  post-partum  haemor- 
rhage, 869 

in  uterine  rupture,  885,  886 

use  of,  during  labour,  359-360 
during  pregnancy,  486 
Erysipelas  during  pregnancy,  559-560 

in  puerperal  state,  560 

Streptococcus  pyogenes  a  cause  of, 
907 
Erythema,  475,  932 
Euphoria,  932 
Eusomphalians,  853 
Eventration,  characteristics  of,  542 
Evisceration,  438,  1073 

indications,  1073 

instruments,  1073 

operation,  1073- 1074 
Evolution,  spontaneous,  434-435 
Exencephalians,  851 
Exostoses  on  pelvic  bones,  787,  789 
Expelling  forces,   anomalies  of  uterus 

unicornis  and  bicornis,  711 
Expulsion,  spontaneous,  435-436 

Fabris   on   amount   of  urine   in   fcetal 

bladder,  848 
Facial    alteration   in    pregnancy,    221, 

227,  233 
Fallopian  tubes,  40,  41,  42,  45 
anatomy  of,  50-52 
changes  in,  during  pregnancy,  215 
during     extra-uterine     pregnancy, 

645-647 
ciliated  lining  of,  641 
development  of,  548 
excision  of,  to  prevent  pregnancy, 

1046 
gravid  and  cornual  pregnancy,  638 
pregnancy  in,  637-672 
Farabceuf,  symphysiotomy,  1052- 1053 
Fehling  on  chorea  during  pregnancy, 

577 
on  kyphotic  pelvis,  775 
on  Stumpf's  theory  of  eclampsia, 
603 
Felheisen  on  erysipelas,  560 
Fever,  effect  on  foetus,  616 
Fibromata  as  cause  of  pelvic  obstruction, 

788 
Fibro-myoma  of  uterus,  791-798 
Fibro-myomata  and  removal  of  uterus, 
1039 


INDEX 


1123 


Fieux  on   peripheral    nerve   lesions  in 

infants,  11 12 
Fischer  on  changes  in  uterine  muscle 
during  involution  of  uterus,  443 
presence  of  peptone  in  urine  during 

puerperium,  451 
on  pulsations  of  foetal  heart  in  face 
presentation,  369 
Fistulae,  712,  729,  730,  789 

and  laceration  of  vagina,  890 
Flatulence  in  pregnancy,  471,  472 
Fleischmann,     increase    in    weight    of 

infant,  1086 
Flint  on  phthisis  during  pregnancy,  562 
Foetus,  abnormalities    of,    as  cause   of 
prolapse  of  cord,  832 
a  cardiac,  521,  819 
accelerated  birth  a  cause  of  lacera- 
tion of  the  cervix,  839 
allantois,  formation  of,  81-83 
alterations     in      normal     relation 
between  shape  of,  and  shape  of 
uterus  a  cause  of  pelvic  presenta- 
tions, 405-406 
anencephalic,  364,  851,  852 
asphyxia  of,  419,  422 

treatment  of, 
attitude,  122-125 
ballottement,  229,  232,  233 
bile,  secretion  of,  103 
bladder  during   intra-uterine   life, 

103,  104 
breech,  dimensions  of,  120,  121 
centre  of  gravity  of,  127 
cessation  of  movements  a  cause  of 

pelvic  presentations,  405,  406 
characteristics     of,     at      different 

months,  104-107 
chorion,  80-81 
chorionic  villi,  89-94 
circulatory  system,  99-103 
'  compressus,'  619 
condition  of,  determined  by  cardiac 
sounds,  185 
of  liver  and  kidneys  in  cases 
of  eclampsia,  601 
cystic  enlargement  of  body,   etc., 

406,  847 
dangerous     effect     of    precipitate 

labour  on,  710 
dead,    method    of    extraction    in 

shoulder  presentation,  438 
death  of,  causes,  295,  581,  615-618 
from     chorea     during     preg- 
nancy, 578- 
from  detachment  of  placenta, 

679,  680,  681 
in  decidual  endometritis,  482 
in     extra-uterine     pregnancy, 
640,  646,  653,  657,  667,  670 
intra-uterine,  614-620 


Foetus,  death  of,  abnormal  development 

from,  617 
conditions  of  ovum  from,  617 
diagnosis,  243,  244 
eclampsia  from,  617 
frequency  of,  614-615 
'  habitual,'  618 
maternal  ancemia  from,  616 
maternal  chronic  renal  disease, 

from,  615,  616 
maternal  diabetes  from,  617 
maternal    endometritis    from, 

616 
maternal    infectious    diseases 

from,  616 
maternal  phthisis  from,  617 
maternal  poisoning  from,  617 
and  '  missed  labour,'  635-636 
parental    syphilis    from,    615- 

616,  617 
symptoms,  618 
traumatic    causes   from,    617- 

618 
treatment,  619-620 
unascertained  causes  from,  618 
persistence    of    tonic    uterine 

spasm  a  cause  of,  716 
presence  of  acetone  in    urine 

an  indication  of,  452 
in  shoulder  presentation,  433 
signs  of,  243-244 
statistics    of,    in   face    presen- 
tations, 387 
in  labour,  299 
use  of  morphia  or  electricity 

with  object  of,  condemned, 

662 
uterine  souffle  heard  after,  184 
vesicular  mole  as  cause  of,  488 
digestive  system,  103-104 
disfigurement  from  face  presenta- 
tion, 379,  387 
ductus  arteriosus,  100- 101,  102 
duration   of  labour  dependent  on 
presentation,  lie,  and  size  of,  285 
early  nutrition  of,  81-104 
effect  of  anaesthetics  on,  359 

of  calcareous  degeneration  of 

the  placenta  on,  522 
of  coiling  of  cord  on,  524,  525 
of  contracted  pelvis  on,  728, 

738 
of  dwarf  pelvis  on,  742-743 
of  elevation  of  temperature  on, 

616 
of  ergot  on  circulation,  360 
of  flat  pelvis  on,  751 
of  funnel-shaped  pelvis  on,  778 
of  gravity  on,  127,  405 
of  hydrocephalus  on,  845 
of  kyphotic  pelvis  on,  776 
71 — 2 


1 124 


INDEX 


Foetus,   effect   of   maternal   conditions 
and  impressions  on,  248 
of  maternal  constipation   on, 

471 
of  hydramnios  on,  507-508,510 
of  maternal  phthisis  on,  563 
of  myoma  of  the  uterus  on, 

798 
of  oedema,  hydrothorax,  and 

ascites  on,  848 
of  oedema  of  the  placenta  on, 

521-522 
of  oligo-hydramnios  on,   511, 

512 
of    osteo-malacic    pelvis    on, 

783-784 
of  pelvic  presentation  on,  417- 

418,  422-423 
of  placenta  marginata  on,  520 
of  placental  infarction  on,  523 
of  presentation  or  prolapse  of 

cord  on,  832-834,  839 
of  primary  uterine  inertia  on, 

713 

of  rachitic  generally  con- 
tracted fiat  pelvis  on,  756 

of  rachitic  triradiate  pelvis 
on,  784 

of  secondary  uterine  inertia, 

715 
of  shoulder    presentation  on, 
and  statistics  of  mortality, 

438 

of  spasmodic  contractions  of 
the  cervix,  719 

of  spasmodic  uterine  contrac- 
tions on,  717 

of  spondylolisthetic  pelvis  on, 

785,  787 
of  syphilis  on,  515-518 
of  tuberculosis  of  the  placenta 

on,  522 
of  unilateral  synostotic  pelvis 

on,  769 
of  use  of  forceps  on,  1004 
of    uterine    contractions    on, 

276,  316 
of  uterine  ruptures   on,   884- 

885 
of    velamentous    insertion   of 

the  cord  on,  528 
of  vesicular  mole  on,  490 
excessive  size  of  entire,  840 
diagnosis,  840-841 
treatment,  841 
excessive  size  of,  due    to  disease, 

843-849 

expulsion,  necessity  of  unin- 
terrupted view  of,  346 

extraction  of,  in  Csesarean  section, 
1044- 1045,  1047 


Foetus,  extraction  of,  in  pelvic  presenta- 
tion, 1016-1035 
foramen  ovale,  99-100,  102 
forces  acting  on,  314 
full-term,  condition  at,  107-109 

weight  and  length  at,  107-109 
funic  souffle,  see  that  title 
head,  blood-supply  of,  102 

changes     in,     as     result     of 

pressure,  278-280 
effect  of  contracted  pelvis  on, 

727,  728,  729  _ 
effect  of  flat  pelvis  on  relation 

to  brim,  750-751 
effect    of    rachitic    generally 
contracted    flat    pelvis   on, 
75.6 
fixation  in  first  stage  of  labour, 
288 
in  premonitory  stage,  287 
moulding  of,  in  brow  presen- 
tations, 393 
in  face  presentations,  379 
in  pelvic  presentations^  1 7 
in  vertex  presentations,  33 1 
position  of,  and  use  of  forceps, 

990-993 
rotation  of,  in  pelvic  presenta- 
tion, 1034-1035 
rotation    in  occipito-posterior 
presentation,  349,  350 
in     vertex    presentation, 
316-319 
unduly  large,  a  cause  of  pos- 
terior  fontanelle    presenta- 
tion, 397 
heart,  see  that  title 
high  rate  of  mortality  from  acci- 
dental  haemorrhage,    692,    702- 
703 
hydrsemia  may  offer  obstruction  to 

birth,  477 
hypogastric  arteries,  97,  101,  102, 

"103 
interlocking,  in  twin  pregnancies, 

820-824 
intra-uterine     infection     of,     with 
enteric  fever,  558 
with  small-pox,  570 
kidneys,  before  birth,  104 
large,  cause  of  abnormal  presenta- 
tion, 367 
length,  method  of  obtaining,  242 
liability   to   infection   of   measles, 

561-562 
•  lie  of,  125 

abdominal  palpation  for  diag- 
nosis of,  166,  172 
oblique,    prior    to    onset    of 

labour,  406-407 
statistics  of  transverse,  426 


INDEX 


1125 


Foetus,  lie  of,  transverse  and  oblique 
lies,    see    Shoulder    under   Pre- 
sentations 
life  of,  determined  by  auscultation, 

.  l83   . 

liver,  size,  structure,  and  function 

of,  103 
macerated,     cause     of     abnormal 
presentation,  367 
and  shoulder  presentation,  429 
maceration  of,  61S-619 
malformations,  173 

connection    with    hydramnios 
and  oligo-hydramnios,  506, 
5io 
and    shoulder    presentations, 

429 
in  twin  pregnancies,  819 
mechanism,    see   tinder   Presenta- 
tions 
meconium,  analysis  of,  103 
method  of  determining  number,  243 
mortality  in  cases  of  prolapsed  arm 
or  hand,  829 
in  labour,  299 
movements  of,  127-128,  188 

a  cause  of  cephalic  presenta- 
tion, 405 
as   signs    of  pregnancy,    229, 
230,  233 
mummification  of,  619 
nervous  system,  104 
nourishment  of,  81,  104 
obstacles  to  birth,  effect  on  uterine 

segments,  268 
ovaries  of,  52 

ovoid,   method  of  predicting  date 
of  delivery  by  length  of,  241-242 
papyraceous,  619,  819 
parts,     interstitial     or    submucous 

myomata  confused  with,  794 
pelvis  of,  28 

pendulous  abdomen,  328 
physiology  of,  99 
position  of,  133-136 

determined  by  abdominal  pal- 
pation of,  166-172 
by  auscultation,  183 
by  cardiac  sounds,  185 
in  kyphotic  pelvis,  775 
Winckel's,  133,  134 
see  also  tender  Presentations 
presentations,  see  that  title 
prolapse  of  cord  favoured  by  faulty 

attitude,  832 
putrefaction  of,  619 

crepitatory  sounds  from,  1S5 
recognition  of  parts  as  a  sign   of 

pregnancy,  229,  230,  233 
relations    of,    to    uterus,    122-136, 
405 


Fn;tus,  salivary  and   gastric  ferments, 
103 
sanguinolentus,  619 
sensation  in  and  voluntary  move- 
ment of  at  birth,  104 
shoulders,   excessive   size  of,   841- 
842 
diagnosis,  842 
treatment,  842-843 
signs  of  suffering  from  undue  pro- 
longation of  labour,  294-295 
sinus  terminalis,  81 
skull,  see  that  title 
sounds  of,  183 

made  by,  185-188 
stomatodxum  in,  first  month,  104 
supply  of  oxygen  to,  93,  94 
syphilis  of,  515-518,  572 
three  stages  of  development,   99- 

103 
transmission    of    uterine    contrac- 
tions to,  311 
trunk,  dimensions  of,  120,  121 
trypsin  in  pancreatic  secretion  of, 

103 
uterus  of,  44 

vernix  caseosa  of,  105-106,  107 
vitelline  circulation,  81-104 
weight  of,  108,  109 
Fontanelles,    and   diagnosis  of    vertex 
presentation,  308-309 
in  fietal  skull,  m-112 
presentations,  see  that  title 
Food    and    drink    during    puerperium, 

456-457 
Foot     or     footling     presentation,     see 

under  Presentations 
Forceps,  action  of,  988-989 

application  of,  in  brow  presentation, 
1003 
in    face    presentation,     1002- 

1003 
in  occipito-posterior   position 

of  the  head,  1001-1002 
in    pelvic  presentation,    1003, 

1034 
in    presentations    other    than 

vertex,  1001 
in    vertex    presentation,    993- 
1001 
indications  for  use  of,  989-993 
introduction  and  history  of,  982-983 
modern,  983-987 
prognosis  of  use  of,  1004 
Forchheimer    on   urinaemic    theory    of 

eclampsia,  603-604 
Formalin,  saprophytic  infection,  930 
Fornix   (see  Vagina),  39 
Fossa  navicularis,  34 
Fothergill  on   changes    after  death  of 
foetus,  482 


1126 


INDEX 


Fothergill   on   douching   during   puer- 
perium,  461 
on  height  of  the  fundus  above  the 
pubis,  268 
Foulerton  on  Bacillus  coli  in  puerperal 
fever,  908 
on    Diplococcus    pneumonias      in 
puerperal  fever,  910 
Fourchette,  32,  34,  238 
Fournier  on  effect  of  syphilis  on  foetus 
and  foetal  appendages,  515,  517 
manifestations    of    non  -  syphilitic 
nature,  517 
Fractures,  infantile,  1109 

pelvic  delormities  from,  787-790 
treatment  of,  1 109 
Fraenkel  on  histology  of  vesicular  mole, 
490 
chorion  the  chief  seat  of  syphilis  in 

the  ovum,  512 
on  origin  of  chorion-epithelioma, 
498,  500 
Frsenulum  clitoridis,  32,  238 
Frankenhaiiser  on  determination  of  sex, 
185 
on  external  pelvimetry,  192 
on  hydramnios,  506 
Franz  on  ovarian  pregnancy,  637 
Frerichs  on  pregnancy  in  diabetics,  581 

theory  respecting  eclampsia,  602 
Freund  on  metastasis  in  chorion-epithe- 
lioma, 504 
on  deviations   from    normal  adult 
type  of  pelvis,  773 
Friction  sounds,  185 
Friedlander    on   nucleated    masses    in 

decidua  serotina,  255 
Fritsch  on  paralysis  from  mitral  stenosis 

in  labour,|592 
Fritz  on  Csesarean  section,  1043- 1044 
Fundus  (see  also  Uterus),  40 
Funic  souffle,  183,  187-188 

presence    of,  suggestive    of    com- 
pression of  cord,  833 
as  sign  of  pregnancy,  230,  233 
Funis,  abnormalities  of,  in  connection 
with  hydramnios,  506 
interruption   of    circulation    in,   a 

cause  of  foetal  death,  617 
lengthening  of,  in   third  stage   of 
labour,  292-293 

Gait,  side  to  side,  of  women,  27,  758 
Galabin  on  removal  of  pelvic  contents 
during  labour,  273 
on  abdominal  pregnancy,  637-638 
on  decapitation  of  foetus,  1073 
on   douching  during   puerperium, 

460 
on  foetal  mortality  in  pelvic  pre- 
sentations, 422 


Galabin   on    heights  of  uterus   during 
pregnancy,  211 
on  internal  version,  1012 
on  maternal  mortality  in  placenta 

prsevia,  702 
on  use  of  forceps   in   pelvic  con- 
traction, 733 
on  spontaneous  version,  433-434 
statistics  of  brow  presentations,  388 
of    foetal    mortality    in    face 

presentations,  387 
of  transverse  lies,  426 
table  of  dates  for  pregnancy,  239- 

240 
term   '  puerperal  fevers '  used  by, 

902 
on  twins  derived  from  one  ovum 
with  two  yolk  sacs,  810 
Galactosuria,  580 
Ganglia  of  Dembo,  254 
Gangrene  in  hydrsemia,  477 
Gardiner   on    mortality   from    cardiac 

disease  in  pregnancy,  590 
Gartner,  ducts  of,  33 
Gassner  on  increase  of  weight  during 
pregnancy,  223 
on   loss    of    weight   during   puer- 
perium, 452 
statistics  of  quantity  and  duration 
of  lochia,  445 
Gaulard    on    children   from   phthisical 
mothers,  564 
on  phthisis  during  pregnancy,  562 
Gebhard  on  origin  of  chorion-epithe- 
lioma, 498 
Genital  canal,  bacteria  in,  142-148,  459 
stenosis  and  atresia  of,  805-807 
tumours  of,  791-805 
Genital  organs,  anatomy  of,  30-57 

duration  of  labour  dependent  on 
condition  of,  285 
Genital  tract,  tamponade  of,  ergot  in, 
981 
indications,  978 
instruments,  979 
operation,  979 
Genital  traumata,  lacerations  of  cervix, 
889-890 
of    vagina,     perinseum,     and 
vulva,  890-894 
rupture     of    pelvic    articulations, 
894-895 
of  uterus,  877-889 
Genitals,    appendages    and    ligaments 
during  puerperium.  447 
bacteriological  zones  of,  147 
bacteriology  of,  142-148 
disinfection  of,  151-154 
external,  Bartholin,  glands  of,  37 
bulbo-cavernosus  muscle,  33 
clitoris,  32,  34 


INDEX 


1 127 


Genitals,  external,  corpora    cavernosa, 

32-33 
fourchette,  32,  34 
hymen,  34-37 
labia  majora,  31-32,  33 
labia  minora,  32 
mons  Veneris,  30-31 
perinreal  body,  38 
scrotum,  31 
urogenital  triangle,  60 
vagina,  30,  33,  34-35,  37-39 
vestibule,  32-34 
internal,  cervix,  42 

Fallopian  tubes,  40,  50 
ovaries,  52-57 
uterus,  40-50 
Gestation,  ectopic,  637 
Giftard,  record  of  cases  of  acute  yellow 

atrophy,  576-577 
Giglio  on  infection  of  fcetus  with  enteric 

fever,  558 
Giles  on  douching  during  puerperium, 
461 
on  quantity  and  duration  of  lochia, 

446 
on  treatment  during  menstruation, 

245 

on  vertical  measurement  of  uterus 
during  puerperium,  446 
Gillette  on  albuminuria  in  pregnancy. 

582 
Glabella  in  fcetal  skull,  in 
Glasgow     Fever     Hospital,    mortality 
returns  in,  enteric  during  pregnancy, 

557 

Gonococcus  in  puerperal  fever,  907, 
910 

Gonorrhoea  during  pregnancy,  551 

Goodell,  method  of  preventing  lacera- 
tion of  the  perinseum,  345 

Gordon  on  infection  of  puerperal  fever, 
905 

Gottschalk  on  origin  of  chorion-epi- 
thelioma, 498 

Graafian  follicle,  ovarian  pregnancy  in, 

637 

Graafian  follicles,  54,  55,  56 

and  twins,  809 
Griesinger  on  pregnancy  in   diabetics, 

58i 
Griffith,  height  of   uterus   above  sym- 
physis during  puerperium,  447 
Grisolle  on   mortality  from  pneumonia 
during  pregnancy,  565 
on  phthisis  during  pregnancy,  563 
Gueniot  on  neurotic  theory  of  eclamp- 
sia, 602 
Gusserow  on  position  of  placenta,  518 
Guy's  Hospital,  statistics  of  brow  pre- 
sentations, 388 
of  face  presentations,  361 


Guy's     Hospital,    statistics     of    fcetal 
mortality,  438,  828 
of  presentation  of  hand  with 

head,  825-826 
of  transverse  lies,  426 
of  twin  presentation,  813 

Hematocele,  639 

pelvic,  663,  665-666 
retro-uterine,  534-535,  654-656 
in  tubal  abortion,  657-658 
Hcematoma,  retro-placental,  282 

of  the  broad  ligament,  639,  651, 

664,  880 
cephal-,  iiio-iiii 
vaginse  et  vulvae,  860-863 
Hrematometra,  235 
Haemoglobinuria  in  eclampsia,  601 
Haemorrhage,  ante-partum,  673-705 
accidental,  682-692 

aetiology,  683 
concealed,  684-687,  882 

dangers  of,  684-685 

diagnosis,  686 

prognosis,  687 

symptoms,  685 

treatment,  686-687 
external,  diagnosis,  687-688 

prognosis,  691-692 

symptoms,  687 

treatment,  688-691 

treatment  in  labour,  689-690 
frequency,  682-683 
during  first  three  months,  673-678 
during      second     three     months, 
diagnosis,  680 

prognosis,  682 

symptoms,  679-680 

treatment,  680-682 
and  removal  of  uterus,  1039 
from  traumatisms,  704-705 
from  tumours,  704 
in  chorion-epithelioma,   503,   504, 

.    505  . 

in   extra-uterine    pregnancy,    639, 

660,  676,  677 
in   extra-peritoneal    rupture,    651, 

664 
in   intra-peritoneal    rupture,    654, 

663,  880 
intra-tubal,  in  tubal  pregnancy,  646 
fcetal,  sub-conjunctival,  379 
in  incomplete  abortion,  630,  631 
infantile,  1109-1111 
in  inversion  of  the  uterus,  896 
late,  see  Secondary  post-partum 
in  liver  in  cases  of  eclampsia,  600 
in  omphalitis,  1108 
post-hpemorrhagic  collapse,  symp- 
toms, 870 
treatment,  870-874 


1128 


INDEX 


Haemorrhage,  post-partum,    350,    351, 

36p,  S°3 
atonic,  863 

causes,  865 

concealed,  868-869 

diagnosis,  865 

factors     which     prevent, 
864-865 

frequency,  864 

prognosis,  868 

treatment,  865-868 
after  hydramnios,  508,  510 
from  myomata,  792>  793j  797 
from  pelvic  contraction,  729 
after  placenta  praevia,  "joi 
in  precipitate  labour,  710 
primary,  859-869 
from    placenta    succinturiata, 

519 
secondary,  465,  869 
aetiology,  869 
frequency,  869 
treatment,  869-870 
in    secondary  uterine  inertia, 

712 
in   spasmodic  contractions  of 

the  cervix,  719 
and  syphilis,  572 
traumatic,  806,  859 
external,  859 

aetiology,  859 
diagnosis,  860 
prognosis,  860 
symptoms,  859-860 
internal,  treatment,  860 
in  laceration  of  the  cervix,  889,  890 
of  perinaeum  and  vulva,  892, 

894 
of  the  vagina,  890,  891 
in  twin  pregnancy,  818-819 
in    uterine  inertia,   712,  713, 

715 
in  rupture  of  uterus,  880,  882, 

886-887 
in  vesicular  mole,  493,  496 
meningeal,  1 1 1 1 

unavoidable,  from  placenta  prsevia, 
692-703 
diagnosis,  696 
prognosis,  7°2 
symptoms,  695 
treatment,  697,  699 
Haemorrhoids,     ante-partum      haemor- 
rhage from,  704 
and   varicose   veins    during   preg- 
nancy, 475 
causes,  475 
symptoms,  475 
treatment,  475-476 
Halbertoma  on  anaemia  of  kidneys  in 
eclampsia,  599 


Hall,    Marshall,    method    of    artificial 

respiration,  1099,  1100,  1101 
Hardy  on  placental  expression,  353 
Harrington,   analysis    of  human   milk, 

1087 
Hart,  Berry,  uterine  contractions,  274 
on  asystole  from  mitral  stenosis,  592 
on  detachment  of  placenta,  281-282 
on  extra-peritoneal  rupture,  652 
on  mesometric  pregnancy,  651 
Hasse  on  effect  of  excess  of  COa  in 

placental  blood,  255 
Haultain  on  chorion-epithelioma,  497, 
498,  500,  501-503,  505 
on    frequency    of    pelvic    ovarian 
tumours,  800 
Hauser    on     ante-natal     foetal    tuber- 
culosis, 522 
Heart,    diseases    of,    combined    aortic 
and  mitral  lesions,  595 
mitral  regurgitation,  593-595 
mitral  stenosis,  591-593 
in  pregnancy,  587-595 
valvular,   danger  of  marriage 
in  cases  of,  591 
foetal,  668 

auscultation  of,  182-183 
in  face  presentation,  369,  370 
in  molar  pregnancies,  493 
rate    during   uterine   contrac- 
tions, 284,  833 
as  sign  of  pregnancy,  230,  233 
in  vertex  presentation,  309 
hypertrophy  of,  449 
Hecker    on   face    presentation    and    a 
dolicho-cephalic  head,  366 
on  foetal  mortality  from  syphilis,  515 
on  funic  souffle,  187 
on  head  presentation,  830-831 
on  increase  of  weight  during  preg- 
nancy, 222  223 
on  mortality  in   interstitial   preg- 
nancy, 649 
statistics    of    foetal    mortality    in 
pelvic  presentations,  422 
of  positions  in  pelvic  presenta- 
tions, 407 
of  prolapse  of  cord,  829 
on   weight   and   length   of  foetus, 
108,  109 
Hegar  on  abortion,  623 

sign  of  pregnancy,  180, 181,  232,  233 
absence  of,   in  intra-uterine  preg- 
nancy, 661 
on  urinaemic  theory  of  eclampsia, 
603-604 
Helme  on   changes  in  uterine  muscle 

during  involution  of  uterus,  443 
Hennig  on  spurious  labour,  648 

on  position  of  the  placenta,  518 
Hense  on  cancer  of  uterus,  799-800 


INDEX 


ri29 


Herman  on  cause  of  foot  or  knee  pre- 
sentation, 406-407 
on  diagnosis  of  contracted  pelvis, 

723 

on  extraction  in    pelvic  presenta- 
tion, 1036 

on  foetal  ascites,  847 

on   moulding    of    head    in    pelvic 
contraction,  728 

on    mortality    in    pelvic    presenta- 
tions, 422 
in   anterior    asynclitism,    329- 
330 

on  internal  pelvimetry,  198 

on  inter-spinous  and   inter-cristal 
distances,  725 

on  Johnson's  method   of  internal 
pelvimetry,  195 

on  management  of  multiple  preg- 
nancy, 817 

on  mortality  in  eclampsia,  61 1 

on  rachitic  flat  pelvis,  745 

on    rotation   of  the  fcetus    by  ex- 
ternal manipulation,  348 

on  secondary  uterine  inertia  and 
tonic  contractions,  714 

on  spontaneous  version,  433-434 

on  temporary  paralysis,  423 

on   treatment    of    prolapsed    arm 
alongside  head,  828 
Hernia  of  pregnant  uterus,  546,  547 
Herrgott  on  bacterial  theory  of  eclamp- 
sia, 602 

on  kyphotic  pelvis,  775 
Hervieux  on  diphtheritic  endometritis, 

923 
on  puerperal  fever,  904 
Heschl    on    weight     of    uterus    after 

delivery,  446 
Heteralians,  854 
Heterotypians,  854 

Hicks,   Braxton,    on   bi-polar  version, 
1008 
on  contractions  of  uterus,  229,  236 
on  treatment  of  placenta  previa, 
698,  699,  700,  701,  702 
Hilus  of  ovary,  52-53 
Himmelfarb     on     cornual    pregnancy, 

658-659 
Hips,  congenital  dislocation,  pelvis  of, 

757-759 
Hirtzmann  on  vesicular  mole,  489 
His,  sinus  terminalis  of,  81 

on    site   of   fertilisation    of  ovum, 
642 
Hochsinger   on    syphilitic    foetus,    516- 

Hofbauer  on  use  of  nuclein  in  lymph- 
atic sepsis,  934 

Hoffmeier  on  cilie  of  Fallopian  tubes, 
641-642 


Hofi'meier  on   induction  of  premature 
labour  in  nephritis,  586 
on  mortality  from  nephritis,  586 
on    presence    of    sugar    in    urine 

during  puerperium,  451 
on  reflexal  placenta,  694 
llohl  on  abdominal  palpation,  164 
on  bi-polar  version,  1008 
on  uterine  souffle,  184 
on  positions  in  shoulder  presenta- 
tions, 430 
'  Hollow  mole,'  490 
Holmes  on  accidental  hemorrhage,  683 
on     contagiousness     of     puerperal 
fever,  906 
Holt  on  human  milk,  1088-1089 

cream  and   sugar  solutions  recom- 
mended by,  1092 
on  infantile  cephalhematoma,  nil 
on  infants'  food,  1095 
on  milk  secretion,  449 
on  peripheral  lesions,  1 1 13 
tables  re  feeding  of  infant,    109 1, 

1092,  1093,  1095 
on  thrush,  1105 

on  use  of  drugs  for  infantile  con- 
stipation, 1 103 
Hough  on  vaginal  douching  with  cor- 
rosive sublimate,  153 
Hubrecht  on  the  trophoblastic  cells,  89 
Hugenberger  on  presentation  of  cord 
and  marginal  insertion,  831 
statistics     of     internal      traumatic 
hemorrhage,  861 
of  presentation  of  hand  with 

breech,  829 
of  presentation  of  hand   with 

head,  825 
on  mortality  of  osteo-malacic 
pelvis,  783 
Hull  on  Cesarean  section,  1037 

on  symphysiotomy,  1050 
Hutchinson    on   transmission  of  syphi- 
litic infection  to  ovum,  517-518 
Hydatidiform  mole,  see  Vesicular  mole 
Hydremia  during  pregnancy,  477 

treatment,  477-478 
Hydramnios,  505-510 
etiology,  505-507 
cause   of  abnormal    presentations, 
367,  406 
of     accidental     hemorrhage, 

684 
of  prolapse  of  cord,  832 
of    compound    presentations, 

827 
of  shoulder  presentation,  428 
connection  with  syphilis,  572 
with  diabetes,  581 
with  hydrocephalus,  S44 
with  twin  pregnancies,  818 


11 3° 


INDEX 


Hydramnios,  constitution,  505 

diagnosis,  508-509 

frequency,  505 

mercurial  treatment  of,  509 

prognosis,  510 

source  of,  507 

symptoms,  507-508 

treatment,  509-510 

varieties,  505 
Hydrencephalocele,   or   encephalocele, 

foetal,  845-846 
Hydrocephalic  head,  406 
Hydrocephalus,  aetiology,  844 

diagnosis,  844 

effect  on  brain  and  skull,  843-844 
on  labour,  844-845 

foetal,  definition,  843 

frequency,  844 

prognosis,  845 

treatment,  845 
Hydromeningocele,  foetal,  845-846 
Hydronephrosis,  foetal,  848 
Hydrops  amnii,  see  Hydramnios 
Hydrorrhoea  gravidarum,  483,  484.  485 

decidual  and  amniotic,  485,   486- 
487 
Hydrothorax,  foetal,  847-848 

effect  upon  labour,  364,  847 
Hymen,  34-37 

1  folding, '  238 

in      virginity,      nulliparity,      and 
parity,  237-238 
Hyperemesis    gravidarum,    469,    470, 

595-597. 

auto-intoxication,  cause  of,  596 

frequency,  595 

neurosis  a  cause  of,  595 

prognosis,  597 

rarity  of,  595 

renal  disease  a  cause  of,  596 

symptoms,  596 

treatment,  596-597 
Hypertrophy  of  cervix  uteri,  544-546 
Hypnotics,  insomnia  during  pregnancy, 

479 

Hypoblast,  structure  of,  53,  74,  78 

Hyrtl  on  anomalies  of  development  of 
umbilical  cord,  527-528 
on  funic  souffle,  188 

Hysterectomy,  1039,  1040,  1046- 1049 
in  cancer  of  uterus,  798,  799 
in  chorion-epithelioma,  870 
in  local  septic  infection,  930 
for  myoma  of  the  uterus,  797,  798 
in  uterine  rupture,  887,  888 

Hysteria  in  pregnancy,  607 

Icterus     neonatorum,     idiopathic     or 
physiological,  1 106- 1 107 
setiology,  1 106- 1 107 
treatment,  1 107 


Iliac  spine,  27 
Iliacus  muscle,  63 
Ilium,  5,  6 

Incarceration    of  retro-deviated    preg- 
nant uterus,  531-537 
Infant,   acute  infective  diseases,   1107- 
1109 
alimentary    system,    diseases     of, 

1102-1106 
asphyxia  neonatorum,  1097- 1 102 
constipation,  1102-1103 
diarrhoea,  1103-1105 
dressing  of  umbilical  wound,  1083 
feeding  of,  1086- 1096 
artificial,  1090- 1094 
breast-feeding      by      mother, 
1086- 1089 
by  wet-nurse,  1089-1090 
by  proprietary  foods,  1090 
icterus  neonatorum,  1 106- 1 107 
ligation  of  cord,  1079-1082 
management  after  birth,  1079 
mastitis,  1108-1109 
meconium,  1085 
mortality    statistics  during    birth, 

299 
nerve  lesions,  1111-1112 
ophthalmia  neonatorum,  1107 
temperature,      pulse,      respiratory 

rate,  1084 
thrush,  ]  105-1106 
toilet,  1082- 1083 

traumata  during  birth,  1109-1113 
haemorrhages,  1109-mi 
fractures,  1109 
umbilical  infection,  1107-1108 
urine,  1084- 1085 
weight,  1085-1086 
Infection,  autogenetic,  142,  147 

hetrogenetic,  142 
Infectious  diseases    during   pregnancy, 

554-575 
and  acute   decidual   endometritis, 
48c 
Influenza  in  pregnancy,  560  561 
Iniopes,  855 

Insanity,  delusional,  940 
of  lactation,  944-945 
of  pregnancy,  940-989 
of  puerperium,  942-943 
insomnia  a  cause  of,  478 
Insomnia  during  pregnancy,  478 

treatment,  478-479 
Internal   version    [see   under  Version), 

1010 
Intestinal  sounds,  184-185 
Intestines,  changes  in,  during  pregnancy, 

218 
Ischio-coccygeus  muscle,  62 
Ischiopagous  monsters,  856 
Ischuria  paradoxa,  473,  532 


INDEX 


1131 


Jackson   on   abortion    from    relapsing 

fever,  566 
Jacquemain's  sign  of  pregnancy,  231 

on  fcetal  movements,  229 
Jardine    on    cardiac    diseases     during 
pregnancy,  589,  591,  592 
on    degeneration    of    the    uterine 

muscle,  879 
on  habitual  death  of  fcetus,  620 
saline  infusions  in  eclampsia  intro- 
duced by,  610 
Jaundice     of    newly-born    infant,    see 
Icterus  neonatorum 
and    ligation    of    the    cord    after 
birth,  1086 
Jellett,  statistics  of  Rotunda  Hospital, 
140 
cat-gut  steriliser  of,   151 
Jewett  on  douching  during  puerperium, 

461 
Johnson  on  internal    pelvimetry,    194- 

195 

Johnston,    clinical  reports  of  Rotunda 

Hospital,  140 
Jolly,  statistics  of  frequency  of  rupture 

of  the  uterus,  877 
Tones.  Bence,  on  urine  in  chorea,  579 
Jungbluth,  vasa  propria  of,  98,  506 
Jurgens  on  necrosis  of  liver  in  eclamp- 
sia, 600 
Jussieu,  De,  on  milky  metastasis,  905 

Kabierske,    statistics    of    duration    of 
expulsion  of  placenta  when   left   to 
nature,  291 
Kaltenbach  on  detachment  of  placenta, 

683 
Kaltenbach    on    frequency  of  placenta 
prsevia,  692 
on  presence  of  sugar  in  urine  during 
puerperium,  451 
Karyokinesis,  443,  448 
Katatonia,  940,  942 
Kehrer    on    foetal     heart-rate    during 
uterine  contractions,  284 
peristaltic  character  of  uterine  con- 
tractions in  animals,  261 
Kellar  on  non-ligation  of  cord,  108 1 
Kelly  on  Cesarean  section,  1040- 1041, 
1042-1043,  1046 
on  disinfection  of  the  hands,  149- 

ISO 
method    of    saline    infusion    into 

cellular  tissue,  873 
on  tubal  pregnancy,  675 
Kennedy,    Evory,    on    auscultation    of 
the  uterus,  182-183 
on  funic  souffle,  187 
on  hernia  of  pregnant  uterus,  546 
Kergaradec,    Lejumeau,    on    ausculta- 
tion of  the  fcetal  heart,  182 


Kerr,  case  of  quintlets  recorded  by,  809 
Kidneys,  see  also  Nephritis 

action  during  pregnancy,  246 
acute  and  chronic  diseases  of,  and 

eclampsia,  601 
changes     in,     during     pregnancy, 

218 
diseases  of,  a  cause  of  foetal  death, 

.   6l5 

in  eclampsia,  598-599 

fcetal,   changes   in,  from   syphilis, 

516-517 

cystic  degeneration,  848 
weight  of,  453 
of  pregnancy  {see  Nephritis),  583- 

587. 
relapsing,      of      pregnancy      {see 
Nephritis),  583-587 
Kilian  on  spondylolisthetic  pelvis,  784 
Kinkead  on  non-recumbent  position  in 

puerperium,  912 
Kirkland  on  puerperal  fever,  906 
Kiwisch  on  the  delivery  of  the  after- 
coming  head,  1030 
on  the  induction  of  labour,  971 
on  uterine  souffle,  184 
Klein  on  placenta  marginata,  520 
statistics  of  kyphotic  pelvis,  775 
of  uterine  ruptures,  888 
Kleinwachter,  birth  corpore  conduplicato, 

435 
Klotz  on  acute  decidual  endometritis, 

480 
Knapp  on   acetone   in   urine   prior  to 

delivery,  452 
Knee  presentations,  see  under  Presen- 
tations 
Kobelt,  pars  intermedia  of,  33 
Koenig,   analysis  of  human  and  cow's 

milk,  1088 
Kolliker  on  changes  in  uterine  muscle 

during  involution  of  uterus,  443 
Kraepelin   on   katatonia   in    puerperal 

insanity,  943 
Kristeller's  method  of  expressing  fcetus, 
712 
management     of    multiple     preg- 
nancy, 817 
uterine  inertia,  712 
Kronig    on    gonococcus    in    puerperal 
fever,  910 
on  vaginal   bacteriology,  143-144, 
145-146 
Kiichenmeister   on   capacity    of    lungs 

during  pregnancy,  588 
KussJ  on  fcetus  and  placental  tubercu- 
losis, 522 
Kiistner  on  placenta  marginata,  520 
on    mortality   of    symphysiotomy, 
1059 
Kyphosis,  723,  784 


TI32 


INDEX 


Labia,  hydrsemia  of,  477 

majora,  31 

minora,  32 
Labour,  accessory  muscles  of.  289 

anaesthetics  during,  357-359 

causes  of,  253-256 

classes  of,  253 

change  in  uterus  during,  258-271 

contracted  pelvis,  effect  of,  on,  727- 

730 
contractions  of  accessory  muscles, 
263 
of  voluntary  muscles  of,  414 
course  of,  diagnoed  by  abdominal 

palpation,  172 
definition,  253 
delayed,  635,  636 
douches  during,  246 
duration  of,  285,  287,  289,  291 

in    cases  of  occipito-posterior 
position  of  the  vertex,  326 
effect  of  cancer  of  uterus,  798 

of  compound  presentations  on, 

826,  827,  828 
of  fetal  hydrocephalus,  844- 

845 
of  infectious  fevers,  554-556 
of  myomata  on,  791-794 
of  oedema,    hydrothorax   and 

ascites,  847 
of  ovarian  tumour,  800-801 
ergot,  use  of,  during,  359-360 
false,  640,  648,  668,  670 

pains,  286,  287 
full-term   and    miscarriage,    differ- 
ences between,  683 
inversion  of  uterus  during,  895-897 
function  of  liquor  amnii  in,  98 
loss  of  blood  during,  see  Haemor- 
rhage 
loss  of  weight  during,  452 
mechanism,  309-331 
missed,  618,  635-636,  670 
diagnosis,  636 
symptoms,  636 
treatment,  636 
mortality  during,  296-299 
moulding  of  head  during,  331 
in  multiple  pregnancies,  see  under 

Pregnancy 
obstructed,    cause    of    rupture    of 

uterus,  877-878 
ovarian  tumours  during,  800-801 
pains,  261-262 
phenomena  of,  257-284,  286 
posture  during,  dorsal  position,  334- 

335 
knee-chest  position,  335-336 
side  position,  334 
Trendelenburg's  position,  336- 

337 


Labour,  posture  during  Walcher's  posi- 
tion, 337-338 
precipitate,  710 

aetiology,  709-710 
cause     of    inversion    of    the 
uterus,  896 
of    post-partum    haemor- 
rhage, 865 
treatment,  710 
preliminary  pains,  261-262 
premature,  635 

caused    by   infectious    fevers, 

559,  56o,  562,  564,  565 
causes,  635 
from  chorea,  578,  579 
date  for  induction  of,  in  con- 
tracted pelvis,  734-735 
induction  of,  968-971 

in  cardiac  diseases,  589, 

593 

in    cases    of    contracted 
pelvis,   753,    769,  776, 

778,  783>  787 
in  cases  of  habitual  death 

of  foetus,  620 
in  cases  of  hyperemesis, 

597 

in  insanity  of  pregnancy 

condemned,  940 
in  nephritis,  586 
in    unavoidable    haemor- 
rhage, 698 
symptoms,  635 
treatment,  635 
preparation  for,  332-334 
presumed  date  of,  239 
prognosis  of,  295-299 
prolonged,  symptoms  of,  293  295 
relaxation      and      contraction     of 
muscle    fibres    and     cervix    in, 

257 
stages,  256-257 
first— 

of  dilatation    of    cervix, 

287-288 
management  of,  339-340 
premonitory,  286-287 
second — 

of  expulsion,  288-291 
management  of,  340-350 
third- 
management  of,  350-357 
or  placental,  291-293 
stenosis  and  atresia  of  the  genital 

passages  during,  805 
symptoms     of    unduly    prolonged 

labour,  293-295 
treatment  of  myomata  during,  794- 

797 
tumours  of  the  uterus  during,  791- 
800 


INDEX 


"33 


Labour,   tumours  of  vagina   and  vulva 
during.  804-805 
and  uterine  inertia,  711-715 
La  Chapelle,  Madame,   on  duration  of 
labour,  289 
on  rotation  of  head,  1035 
Lactation,  effect  of  menstruation  upon, 
1089 
insanity  during,  944-945 
management  of,  462-464 
mastitis  during,  946 
over-lactation,    symptoms    similar 

to  phthisis,  563 
prolonged,     a     cause     of     super- 
involution  of  uterus,  951 
Lactic  acid  in  bones,  779 
Langhans'  layer,  90-92,  491,  492 

as    origin    of  chorion-epithelioma, 
498 
Lanugo  hairs  in  liquor  amnii.  98 
Larcher  on  hypertrophy  of  the  heart  in 

pregnancy,  5S7 
Lateral  fornices,   pulsation  in,  as  sign 

of  pregnancy,  232 
Laxatives  in  pregnancy,  246,  471-472 
Lead-poisoning,    intra-uterine  death  of 

foetus,  617 
Leaman,  force  of  uterine  contractions, 

262 
Leeds,  analysis  of  human  milk,  1087 
Lefour  on  pulsations  of  fcetal  heart  in 

face  presentation,  369 
Legrand  on  lead-poisoning,  617 
Legueu  on  cervix  in  molar  pregnancies, 

493 
Lehmann,  ante-natal  fcetal  tuberculosis, 

522 
Lempereuron  maceration  of  fcetus,  618- 

619 
Leopold      on     abdominal     palpation, 
164 
on  decidua  serotina  during  preg- 
nancy, 255 
on  early  human  ovum,  104 
on  uterine  mucosa  during  involu- 
tion of  uterus,  443-444 
Lepage  on  face  presentation,  361 

statistics   of  pelvic    presentations, 
402-403,  464 
Lercy  on  puerperal  fever,  905 
Leucocytosis,  932 

physiological,  450 
Leucorrhcea  in  sub-involution  of  uterus, 

9SO 
Levator  ani  muscle,  62,  319 
laceration  of,  892 
unaffected  by  pregnancy,  216 
Lex  Regia  or  Csesarea,  1036 
Leyden  on  false  nephritis  in  eclampsia, 
598 
on  kidney  of  pregnancy,  583 


Limbs,  changes  in,  during  pregnancy, 

221 
Linese  atrophica,  date  of  appearance, 

217 
Liquor  amnii,  absence  or  insufficiency 
of,  see  Oligo-Hydramnios 
analysis  and  quantity  of,  98 
composition  of,  98 
decomposition  of,  in  uterine  inertia, 

712,  713 

excess  of,  see  Hydramnios 

function  of.  98 

hydrorrhcea,  275 

transmitter   of  intra-uterine    pres- 
sure, 277 

lanugo  hairs  in,  98 

in  normal  labour,  271 

origin  of,  opinions  on,  98 

in  pelvic  contraction,  727,  728,  743, 

7S1.  756 
and   presentation  and  prolapse  of 

cord,  830,  831,  832 
in  syphilitic  fcetus,  515 
Lithopaedion,  formation  of,  636,  640 
Litten  on  abortion  from  scarlatina,  567 
Littlewood,    extra-uterine    pregnancy, 

637 
Litzmann  on  Cassarean  section,  1045 
classification    of    kyphotic   pelvis, 

770 
obliquity  of,  313,  327,  328,  752 
on  position  of  sagittal  suture,  327, 

752 
statistics    of    maternal   and    fcetal 
mortality    in     cases    of    pelvic 
contraction,  738 
statistics   of    unilateral    synostotic 
pelvis,  769 
Liver,  acute  yellow  atrophy  of,  576 
changes  in,  during  pregnancy,  218 
fcetal,    changes    in   fcetal    syphilis, 
516 
structure  and  function  of,  103 
tumours  of,  849 
necrosis  of,  in  eclampsia,  600 
Lochia,  description  of,  444-445 

in  local  septic  infection,  92S-929 
presence  of  bacteria  in,  445 
quantity  and  duration  of,  445-446 
in  saprpemia,  913,  91 4- 91 5,  917 
in  septic  endometritis,  921,  923 
suppression   or   retention   of,    904, 
916,  917 
Lohlein  on  eclampsia  mortality,  613 
Long  Reach  Hospital,  small-pox  mor- 
tality during  pregnancy,  569-570 
Longings  during  pregnancy,  223,  479 
Lorvnberg   on    metastases    of    chorion- 
epithelioma,  504 
Lordosis,  723,  758,  773,  785 
Lower,  tubercle  of,  102 


"34 


INDEX 


Lumbar    cord,    innervation   of    uterus 

from,  254 
Lungs,  congestion  and    necrosis  of,  in 

eclampsia,  600-601 
Luschka  on  synovial  membrane,  17 
Lusk  on  longings,  479 

on  menstruation  during  pregnancy, 

704 
on  pelvic  presentation,  1024 
on  treatment   of  disorders  during 

pregnancy,  479 
on  treatment  of  hydrsemia,    477- 
478.  . 
Lymphangitis,  Streptococcus  pyogenes 
cause  of,  907 
and  vulvar  septic  infection,  920 
Lymphatic  leukaemia,  788 
sepsis,  935 

symptoms,  932 
treatment,  933-934 

Macan  on  abdominal  palpation,  164 
M'Cann  on  date  of  secretion  of  true 
milk,  449 
on  accidental  haemorrhage,  691 
on   urinary   system    during    puer- 
perium,  451 
MacClintock  on  diagnosis  of  twins  by 
auscultation,  815 
expulsion   of  placenta  by  manual 

compression,  353 
hydramnios,  506 
MacDonald,  Angus,  on  cardiac  disease 
and  pregnancy,   587,   589,   590-591, 
592 
Maceration  of  foetus,  618-619 
Mackenrodt  on  tubal  abortion,  657 
McKerron,  statistics  of  ovarian  tumours, 

800,  801,  802 
Macnaughton-Jones  on  'folding  hymen,' 

238 
Madden,  More,  on  vesicular  mole  and 

pregnancy,  488 
Maier   on   recurrence   of  molar   preg- 
nancies, 489 
Mammalia,  deciduate  and  non-decidu- 
ate,  83-84 
lower,  7,  9,  20 
Mammary  glands,  64-68 
abscess  of,  948 
areola  of,  65-66 
blood-supply  of,  68 
changes  in,  during  pregnancy,  218- 

221 
of  newly-born  infant,  1108-1109 
origin,  64 
pregnant,  66-68 
virginal,  66 
Man,  erect  position  of,  20 
Manheimer  on  metastases  of  chorion- 
epithelioma,  504 


Marchand  on  vesicular  moles,  490 

'  chorion  wandering  cell '  described 

by,  503 

on  origin  of  chorion-epithelioma, 

498,  499-500 
Marey  on  foetal  heart-rate,  284 
Marmorek's   serum,  use   in   lymphatic 

sepsis,  933 
Marriage,  danger  of,  in  cases  of  valvu- 
lar cardiac  diseases,  591 
Martin,    R.,    on    effect   of    calcareous 
degeneration  of  the  placenta  on 
foetus,  522 
effect    of    placenta   marginata   on 

foetus,  520 
method  of  delivery,  753,  754,  845, 

1032 
pelvimeter   of,    method   of    using, 

190-193 
placental  lesions  and  albuminuria, 

524 
on  tubal  abortion,  657 
Massman  on  funic  souffle,  187 

statistics  of  treatment  of  presenta- 
tion    and     prolapse     of     cord, 

839 
Mastitis,  465,  946-948 
infantile,  1108 

treatment,  1109 
interstitial,  947-948 
parenchymatous,  948-949 
Maternal    mortality   in    shoulder    pre- 
sentation, 438 
in  labour,  295  299 
sounds,  183-185 

system,   effect  of  uterine  contrac- 
tions on,  284 
Maternite  and  Lariboisiere  Hospitals, 

statistics  of  face  presentations,  361 
Matthews       Duncan,      see       Duncan, 

Matthews 
Mauriceau  method  of  delivery  of  after- 
coming  head,  1032- 1033 
Mayo  on  chorea  in  infants,  578 
Mayo  Robson,  see  Robson,  Mayo 
Mayor  on  pulsations  of  the  foetal  heart, 

182 
Mayrhofer   on   streptococcus   in   puer- 
peral fever,  907 
Measles  during  pregnancy,  561-562 

as  cause  of  acute  decidual  endo- 
metritis, 480 
Meatus  urinarius,  33 

see  also  under  Urethra 
Meckel  on  circular  sinus  of  placenta, 

694 
Meconium,  294-295,  1085 
Medulla,  55,  254 

Meigs  on  puerperal  fever,  902,  906 
Membranes,  abnormal  permeability  of, 
487 


INDEX 


"35 


Membranes,  changes  in  mucous,  during 
involution  of  uterus,  443 
decidual,  examination  after  expul- 
sion, 355-356 
detachment  of,  255 
retained  fragments  cause  of  atonic 

hemorrhage,  865 
rupture  of,  during  labour,  275-276, 
278,  287-288,  290-291 
artificial,  339,   712,  835,  904, 

1007 
in  multiple  pregnancy,  817 
in     pelvic    contraction,     727, 

728 
premature,  339,  718 

in  contracted  pelvis,  732, 

737,  744,  756,  758 
and  presentation  and  prolapse 
of  cord,  830,  831,  832,  S33 
in     postural     treatment     and 

cephalic  version,  437 
prevention,  387,  396,  419,  509 
in    velamentous    insertion    of 
the  cord,  528 
syphilis  of,  512-514 
Menge  on  vaginal  bacteriology,  144 
Menses,   suppression  of,  as   a   sign  of 
pregnancy,  225 
see  also  under  Amenorrhea 
Menstrual  irritation  as  a  cause  of  labour, 

256 
Menstruation     and     determination     of 
duration  of  pregnancy,  205-206, 
239-240 
explanation  of  periodicity  and  con- 
nection with  date  of  labour,  256 
in  extra- uterine  pregnancy,  660 
and  ovulation,  205 
during  pregnancy.  703-704 
treatment  during,  245 
Merriman    on  duration    of  pregnancy, 

206 
Merz,  statistics  of  uterine  ruptures,  888 
Mesoblast,  structure  of,  78 
Metastases  in  chorion-epithelioma,  503, 

5°4,  5°5 
Metastasis,   milky,   supposed   cause    of 

puerperal  fever,  904 
Metritis  as  cause  of  uterine   enlarge- 
ment, 234 
Meyer,  menstruation  and  effect  of  milk 
on  infant,  1088 
statistics  of  Cesarean  section,  1037 
Michaelis  on  prolapse  of  arm  alongside 
head,  827 
statistics  of  shoulder  presentations 
with     normal     and     contracted 
pelvis,  427 
Micturition,  infant,  10S4-1085 

during  puerperium,  454 
Milk,  analysis  of,  1087,  1088 


Milk,  colostrum  corpuscles  in,  448-449 
cow's,  feeding  of  infant,  1090- 1094 
effect  on  infant,  1102,  1 104 
fever,  904 

old  opinion  concerning,  451 
formation  of,  448 
leg,  904 
secretion,  average  daily  quantity, 

449 
date  of  commencement,  449 
during  pregnancy,  220-221 
suppression  of,  during  scarlatina, 
567,  568 
Miscarriage,  633-634 
etiology,  633 
from  diabetes,  581 
symptoms,  633 
treatment,  634 
Money,    modification   of    first    cardiac 

sound  detected  by,  449-450 
Monocephalians,  854 
Monod  on  uterine  souffle,  184 
Monomphalians,  853 
Monosomians,  854 
Mons  veneris,  30-31 
Monsters,  849  858 
single,  850-853 
double,  853-858 
Montgomery    on    '  longings '    in    preg- 
nancy, 479 
on  colour  of  the  vulvar  and  vaginal 
mucous  membrane  in  pregnancy, 

231 

follicles  of,  66,  219,  227 
on  secondary  areola,  220,  228 
on  umbilical  areola,  217 
on  uterine  souffle,  183-184 
Moore  on  enteric  fever   during   lacta- 
tion, 557 
on      mortality     from     pneumonia 
during  pregnancy,  565 
Morisani     on     symphysiotomy,     1050, 

1052,  1053 
Morning  sickness,  469-471 
aetiology,  470 
during  pregnancy,  222 
as  sign  of  pregnancy,  226 
symptoms,  470 
treatment,  470-471 
Mott,  F.  W.,  on  causation  of  insanity, 

941 
Muller  on  date  for  inducing  premature 

labour  in  pelvic  contraction,  735 
Multipara?,  226,  247,  340 

accidental  haemorrhages  in,  683 
albuminuria  less  frequent  in,  582- 

583 

cervical  changes  in,  in  premoni- 
tory stage,  286 

diabetes  in  pregnancy  more 
frequent  in,  581 


1 136 


INDEX 


Multipara,  duration  of  labour,  257,  285, 

289 

of  first  stage  of  labour,  287 

of  second  stage  of  labour, 

289 

eclampsia    in,    rate    of    mortality 

from,  613 
extraction  of  the    pelvic  pole  in, 

1016 
fixation  of  foetal  head,  172,  287 
incontinence   of    urine    not    infre- 
quent, 474        ' 
insanity  of  lactation  more  frequent 

in,  943-944 
loss  of  weight  in,  greater  during 
puerperium   than  in  primiparae, 
452 
micturition  during  puerperium,  454 
pains  during  puerperium,  455 
pelvic  contraction  in,  724 
perineal  lacerations  rare  in,   892, 

893 
placenta  praevia  more  frequent  in, 

692 
prolapse  of  cord  more  frequent  in, 

832 
proportion    of  shoulder   presenta- 
tions in  primiparse  and,  428 
statistics    of    foetal     mortality    in 
pelvic  presentations,  422 
of     infant     mortality     during 

labour  and  after  birth,  299 
of     pelvic     presentations    in, 
402-403 
taking   up  of  the  cervix  in,   265, 

266-267 
vesicular  mole  more    frequent   in, 

than  in  primiparae,  488 
weight  and  length  of  fcetus  in,  108 
Multiple  pregnancies,  see  under  Preg- 
nancies 
Mummification  of  foetus,  619 
Murchison    on    enteric     fever    during 
pregnancy,  557 
on  mortality  from  relapsing  fever 

during  pregnancy,  566 
on  typhus  during  pregnancy,  574 
Murphy  on  cause  of  morning  sickness, 
470 
on  statistics  of  Rotunda  Hospital, 

139. 
Murray,  Milne,  on  compression  of  foetal 
head  with  cephalotribe,  992 
on  use  of  forceps,  1001 
Muscular  susurrus,  185 
Musculo-aponeurotic  canal,  37 
Myelitis,  779 

Myomata,    cause    of  sub-involution  of 
uterus,  949 
diagnosis,  794 
effect  on  labour,  791-794 


Myomata,  intra-uterine,  a  cause  of  ante- 
partum haemorrhage,  704 
pedunculated,  793,  794,  796,  797 
prognosis,  797-798 
treatment,  794-797 
uterine  and  shoulder  presentation, 

427428 
see  also  Fibro -myomata 
Myomectomy  in  secondary  post-partum 

haemorrhage,  870 
Myxoma  chorii,  see  Vesicular  mole 
fibrosum,  521 

Naegele  on  auscultation  of  uterus,  183 
on  erect  position  of  man,  20 
obliquity,  312,  313,  327,  331,  395, 

396,  752,  756 
on  pelvis,  see  Unilateral  synostotic 

under  Pelvis 
positions   of,    133,    303-304,    322, 
323,   324,    367,   374,  407,    414, 
415,  430,  1027 
on  uterine  souffle,  183-184 
Nausea    and    vomiting    during     preg- 
nancy, see  Morning  sickness,  469-471 
Nauss,    statistics     of    mortality     from 

myoma  of  uterus,  798 
Nephritis  during  pregnancy,  517,  524, 
S82 
aetiology,  583 
false,  in  eclampsia,  598 
frequency,  582-583 
pathological  changes,  583 
prognosis,  586  587 
symptoms,  583-586 
Nerve  lesions,  infantile,  central,  nil 

peripheral,  11 12 
Nerves  of  uterus,  49,  50,  254 
Nervous    impressions,    effect   on    milk 
and  infant,  1089 
system,  changes  in,   during  preg- 
nancy, 223,  478-479 
Neugebauer    on    length    of    umbilical 
cord,  524 
statistics   of  mortality  after   sym- 
physiotomy, 1059 
Neuralgia  during  pregnancy,  478 
Neville,  W.  C,  on  abdominal  palpation, 
164 
on  puerperal  fever,  903 
New-born,  the,  see  Infant 
Nicholson,  theory  of  eclampsia,  504 
on  thyroid  extract   for  eclampsia, 
610 
Niemeyer  on  enteric  fever  during  preg- 
nancy, 557 
Nipples,  changes  in,  during  pregnancy, 
219-221 
treatment,  248-249,  462-463 
Nuchal    position    of    arm,    825,    826, 
828 


INDEX 


"37 


Nuclein,  use  in  lymphatic  sepsis,  934 
Nufer,  Jacques,  Cas?arean  section  first 

done  by,  1037 
Nulliparae,  osteo-malacia  rare  in,  779 
Nulliparity,  diagnosis,  236-239 
Nymphte,  see  Labia  minora 

Obstetrical  conjugate,  9 
Obturato-coccygeus  muscle,  62 
Obturator  internus,  64 
Occipito-posterior    positions,    manage- 
ment of,  34S-350 

mechanism  of,  324-327 
(Edema,  fcetal,  847-S48 

diagnosis,  847-848 

effect  upon  labour,  847 
prognosis,  848 
treatment,  848 

in  pelvic  cellulitis,  925 

of  placenta,  521-522 

of  vulva,  476,  477 
Oidium  albicans  in  thrush,  1105 
Oldham  on  '  missed  labour,'  635 
Oligo-hydramnios,  510-512 

definition,  510 

diagnosis,  51 1-5 12 

pathology,  510-511 

prognosis,  512 

symptoms,  51 1 
Olshausen    on    scarlatina  during  preg- 
nancy and  puerperium,  566 

on  pulse-rate  of  parturient  women, 

45° 
Omentum,  accumulation  of  fat  in,  235 
Omphalitis,  1 107- 1 108 
Omphalosite's,  850 
Oophoritis  {see  Salpingitis),  925 
Ophthalmia  neonatorum,  1083,  1107 
Opiates  in  secondary  inertia,  715 
Os  externum,  42 

dilatation  in  premonitory  stage,  286 
Os  internum,  42 

dilatation    in    premonitory   stage, 
286,  287,  288 

during  puerperium,  442 
Ossa  innominata,  5 

in  rachitic  flat  pelvis,  749,  75° 

in  transversely  contracted    pelvis, 

771,  774 
Osseous   system,    changes    in,    during 

pregnancy,  223 
Osteitis,  779 
Osteo-chondritis,  516 
Osteomalacia  in  contracted  pelvis,  722, 

723 

in  the  triradiate  pelvis,  779-780 
reason  for  Cesarean  section,  441 

Osteo-sarcomata,  788 

Otocephalians,  852 

Ould,     Fielding,     episiotomy     recom- 
mended by,  346 


Ouvry  on  use   of  X    rays  to  discover 

vesicular  mole,  495 
Ovaries,  52 

changes     in,    during     pregnancy, 

215 
erst  in,  534 
structure  of,  53 

tumours  of,  during  labour,  800-804 
during   pregnancy,   235,    552- 

553 
Ovariotomy,  801,  802,  804 

risks  during  pregnancy,  553 
Oviduct,  see  under  Fallopian  tubes 
Ovum,  69 

abnormalities,  obstetrical  causes  of 

mortality,  295 
abortion,  622 

amnion,  formation  of,  78-81 
apoplectic,  481-482 
blastodermic  vesicle,  72 
in  cervical  abortion,  629 
changes   in,    in    tubal    pregnancy, 

645-646 
conditions    of,    causes     of    intra- 
uterine foetal  death,  617 
death  of,  646,  650,  656 

see  also  Foetus,  death  of 
decidua,  relation  to,  84-85 
detachment  and  expulsion  due  to 

maternal  endometritis,  616 
effect  of  syphilis  on,  571 

of  uterine  contractions  on,  263, 

275-284 
of  vesicular  mole  on,  490 
embryo,  formation  of,  74-78 
expulsion  due  to  uterine  contrac- 
tions, 253 
fertilisation,  71-73 
fcetus,  early  nutrition  of,  81 
hsemoirhage   due    to   degeneration 

of,  678-679 
maturity  of,  70 

normal  site  of  fertilisation,  641-644 
obstructions    to    descent    of    ferti- 
lised, 643-644 
premature  expulsion,  488 
prior  to  fertilisation,  69-71 
in  rupture  of  tube,  639640 
segmentation,  73 
syphilis  of  the,  512-518 
transmission  of  tuberculosis  to,  564 
zona  pellucida,  6q  70 
Oxytocics  in  abortion,  622 

Pajot  on  induction  of  labour  in  kidney 
of  pregnancy,  586 
manoeuvre  in  forceps-delivery,  985 
on  menstruation  during  pregnancy, 
703 
Palmer  on  menstruation  during  preg- 
nancy, 704 

72 


IT38 


INDEX 


Pancreas,  necrosis  and  anaemia  of,  in 

eclampsia,  600 
Paracephalians,  850 
Paralysis,  facial,  of  infant,  11 12 

general,  in  insanity  of  pregnancy, 

940,  941 
of  sphincters,  451 
Parametritis,  925,  926 

from  incomplete  abortion,  630 
unilateral,  664,  665 
Parasites  or  foetal  masses,  850,  852 

double,  854,  855-856 
Pare  on  vesicular  mole,  488 
Parietal  bones,  fcetal,  312-313 
Parity,  diagnosis  of,  236-239 
Park,  Roswell,  on  pyaemia,  934 
Parturient  canal,  310 
Partus  immaturus,  253,  633 
maturus,  253 
prematurus,  253,  685 
serotinus,  253,  635 
Parvin  on  coition,  248,  479 

on  albuminuria  in  pregnancy,  582 
on  menstruation  during  pregnancy, 
704 
Pasteur  on  Streptococcus  pyogenes  907 
Pelvic     presentations,     connection     of 

period  of  delivery  and,  401-402 
Pelvimeter,    internal,  mode   of  using, 
199-202 
points  to  be  observed  in  use 

of,  202 
Martin's  190-193 
Skutsch's,  199-202 
Pelvimetry,  189-202 

diagnosis  of  contracted  pelvis  by, 

724-726 
external,  190-193 
value  of,  193 
internal,  194-195 
Pelvis,  anatomy  of  bony,  3-29 
axis  of,  13-15 
cavity  of,  7-8,  26 
cellular  tissue  of,  63-64 
cellulitis  of,  925-926 
centre  of  gravity  of  body,  24 
contracted,  365,  398,  406 

absolute  contraction,  738 
bilateral  synostotic,or  Robert's 

pelvis,  724 
and  Cesarean   section,    1038, 

1039 
a  cause  of  shoulder  presenta- 
tions, 427 
classification     and      degrees, 

720-721,  730 
symptoms  during,  726-727 
of   congenital    dislocation    of 

the  hips,  757-759 
and  craniotomy,  1060,  1064 
definition,  720 


Pelvis,  contracted,  diagnosis,  723-726 
frequency  of,  722 
generally  contracted  flat,  722, 

735   .       • 
and       inducing       premature 

labour,  734-736 
irregularly  compressed  or  tri- 

radiate,  778-784 
more  frequent  on  the  Conti- 
nent, 426 
obliquely  distorted,  761-769 
and  pelvic  presentation,  418 
and  presentation  and  prolapse 

of  cord,  829,  831 
prophylactic   podalic  version, 

730-733,  734,  736"737,  744. 

745.  753-754,  757,  776 
and     symphysiotomy,      1053, 

1054 
symptoms  during  labour,  727- 

730 
during    pregnancy,    726- 
727 
transversely   contracted,    769- 

776 

treatment,   Csesarean   section, 

733,734,737,738,745, 

753,  769,  776,  778,  782, 

783,  784,  787 

craniotomy,  733-734,  737, 

738,  745,  776,  783,  784 

unilateral      synostotic,       765- 

769 
and  use  of  pelvis,  993 
contraction  of,  cause  of  secondary 

uterine  inertia,  713 
coxalgic,  761,  764-765 
deformed,  see  Contracted,  above 
development  of,  28 
diameters  of,  8 
diaphragm  of,  changes  in,  during 

pregnancy,  216 
duration  of  labour  dependent  on 

condition  of,  285 
dwarf,  742-745 
effect   of  uterine   contractions    on 

pelvic  contents,  271-273 
extra-uterine  septic  lesions  of,  925- 

927 
external  measurements,  13 
false  and  true,  6 

anterior    fontanel  le   presenta- 
tion in,  394-395-  39° 
a    cause    of    compound    pre- 
sentation, 826 
non-rachitic,  745-747 
rachitic,  745,  747-754 
treatment,  732 

symphysiotomy,  734,  737, 

745,  754 
version,  736 


INDEX 


"39 


Pelvis,  false  and  true,  use  of  forceps,  731 
see  also  Contracted,  above 
floor  of,  anatomy  of,  30 

changes  in,  during  pregnancy, 

216 
changes    during    puerperium, 

448 
diaphragm,  62-63 
weakening  of,   from   perineal 
laceration,  892 
inlet  of,  7 
outlet  of,  7 
funnel-shaped,  726,  776-778 
inclined  planes  of,  15 
joints  and  ligaments,  15 

effect  of  uterine  contractions 
on,  274-275 
joints,  condition  during  pregnancy 

and  puerperium,  453 
joints  of,  221 

kypho-scoliotic,  761,  762-764 
kyphotic,  726,  770,  773-776 
lumbo-sacral  articulation,  17 
male  and  female,  1,  25 
measurements  of,  racial  differences 

in,  12-13 
mechanism  of  labour  in  connection 
with,  in  vertex  presentation,  309 
muscles  of,  cellular  tissue,  63 
iliacus,  63 

obturator  internus,  64 
psoas,  63 
pyriformis,  64 
myoma  situated  in,  794,  795 
Naegele's,  see  Contracted  unilateral 

synostotic 
nana,  742-745 
non-rachitic   generally    contracted 

flat,  755 
obtecta,  773,  784,  786 
organs  of,  bladder,  58 

rectum,  58 
os  pubis,  5,  6,  32 
os  innominatum,  5 
osteomalacic,  722,  778-784 
ovarian  tumours,  800 
peritonitis  {see  Peritonitis),  925 
presentation  of,  see  that  title 
rachitic,  725,  755,  757 

generally       contracted       flat, 

755-757 
triradiate,  784 
relation  of  foetus  to,  125,  135 
Roberts  {see   Contracted   bilateral 

synostotic,  above),  726 
rotation  of  pelvic  girdle,  337 
rupture  of  the  pelvic  articulations, 
894 
aetiology,  894 
diagnosis,  894 
treatment,  895 


Pelvis,      sacro-coccygeal     and      inter- 
coccygeal  joints,  17 
sacro-sciatic  ligaments,  18-19 
sacrum,  3-5 
split,  790 

spondylolisthetic,  722,  784-787 
symphysis  pubis,  18 

see  also  that  title 
transmission  of  body-weight,  22-25 
unduly    large,    cause    of    anterior 
fontanelle  presentations,  394 
Peptone  in  puerperal  urine,  451-452 
Perforation,  necessity  for,  393,  398,  778 
in  excessive  size  of  fcetus,  841 
in  foetal  hydrocephalus,  845 
method  of  performing,  1064- 1067 
Periarteritis,  syphilitic,  lesions  of  cord 

in,  515. 
Pericarditis  and  peritonitis,  927 
Perimetritis  {see  Peritonitis,  pelvic),  926 
Perineal  body,  273 

in  male  and  female,  38 
peculiar  to  female,  38 
Perinaeum,  412 

changes  during  puerperium,  448 
dilatation,   necessity    for    uninter- 
rupted view  of,  346 
effect  of  uterine  contractions  on, 
and  on  neighbouring  structures, 
273-274 
and  internal  rotation,  316-317 
laceration  of,  890,  891 
aetiology,  892 
degrees,  891-892 
diagnosis,  892-893 
prevention  of,  341-346,  420 
symptoms,  892 
treatment,  891,  893 
Peritoneum,  41,  43 

bladder  stripped  of,   during  preg- 
nancy, 217 
changes  during  involution  of  the 

uterus,  442 
stripping  of,  in  meso-metric  preg- 
nancy, 651-652 
uterine,    changes   in    reflection    of 
during  pregnancy,  215 
Peritonitis,  932 

and  foetal  ascites,  847 
general,  927-931 
pelvic,  926 

from      incomplete      abortion, 
630,  631 
Pernice,    statistics    of    presentation   of 

hand  with  head,  825 
Perret  on  cause  of   internal  traumatic 

haemorrhage,  862 
Peters  on  early  human  ovum,  87,  104, 
498,  500 
on  urinremic  theory  of  eclampsia, 
603 

72 — 2 


H40 


INDEX 


Pfeiffer  on  colostrum  and  milk  analysis, 
1087 
on    composition    of    milk    during 
first     fortnight     of      lactation, 
1089 
Phlebitis  in  septic  infection,  924 

Streptococcus  pyogenes  cause  of, 
907 
Phlebo-thrombosis,  crural,  septic,  938 
symptoms,  939 
treatment,  939-940 
varieties  of,  938-939 
Phlegmasia  alba  dolens,  939 
Phloridizin  in   oligohydramnios,   510- 

Phthisis,  562-564 

maternal,  a  cause  of  foetal  death, 
617 

during  pregnancy,  562-564 
Physiological  icterus,  1 106- 1 107 
Pica,  see  Longings 
Pick  on  hyperemesis  gravidarum,  595, 

596 
Pilliet  on  liver  in  eclampsia,  600 
Pinard  on  the  expulsion  of  the  placenta, 

283 
on  abdominal  palpation,  164 
amnion     more     permeable     than 

chorion,  275 
on  amniotic  and  decidual  hydror- 

rhoea,  485 
bathing  of  infant  inadvisable  until 

healing  of  navel,  1083 
on  cephalic  application  of  forceps, 

994,  1000 
on  fostal  cardiac  sounds,  185 
on  funic  souffle,  188 
on  injection  of  urea  in  eclampsia, 

602 
on  menstruation  during  pregnancy, 

703 

on  operating  in  extra-uterine  preg- 
nancy, 671 

on  'placenta  truffe,'  524 

on     position     of     the     placenta, 

5l8.    . 

on  statistics  of  pelvic  presentation, 

402 
of  duration  of  multiple  preg- 
nancies, 818 
of  face  presentation,  361 
of  mortality  in  symphysiotomy, 

1059 
of  positions  in  vertex  presen- 
tation, 304 
of  transverse  lie,  426 
of  presentations  in  twin  preg- 
nancies, 813 
on   the   cessation    of  hemorrhage 

after  delivery,  271 
treatment  of  hydramnios,  509 


Pinard    and    Lepage    on   duration    of 
second  stage  of  labour,  289 
statistics  of  cephalic  presentation, 

300 
on  duration  of  labour,  285 
Pincus  on  use  of  atmocausis  in  phthisis, 

564 
Placenta,  analysis  of,  95 

anomalies  and  diseases  of,  518-524 

in  twin  pregnancies,  819 
'battledore,'  520,  528 
circular  sinus  of,  694 
circulation  at  full  term,  102 
confusion    of    portions    of,    with 

chorion-epithelioma,  504 
description  of,  89 

detachment  and  expulsion  of,  280- 
284,  291-293,  350-356 
in     multiple    pregnancy, 

8i5 

due  to  tension  of  cord,  524 
from    fall   or   blow  cause    of 

intra-uterine     foetal    death, 

618 
in  hydramnios,  508 
in  primary  uterine  inertia,  712 
hemorrhage  from,  678-682 
premature,  effect  of  partial,  on 

foetus,  1097 
in  case  of  twins,  817 
diseases  of,   cause  of  miscarriage, 

633 
effect  of  ergot  on,  360 
functions  of,  93-95 
growth  of,  after  death  of  fo?tus,  647 
importance  of  relations  of,  to  ovum 
in  extra-peritoneal  rupture,  652 
infarction  of,  in  eclampsia,  601 
Jungbluth,  vasa  propria  of,  98 
low  insertion  of,  832 
manual  removal,  875-876 
marginata,  526 
membranacea,  518-519 
and  myoma  of  the  uterus,  797 
a  passage  for  waste  materials,  95 
previa,  406,  518,  679-687, 692-703, 
7i8 

etiology,  692-694 

Barnes'  treatment,  700-701 

Braxton  Hicks'  treatment,  698 

a  cause  of  post-partum  hemor- 
rhage, 865 

central,  695 

Champetier    de    Ribes'   bag, 
699,  700,  701,  702 

complications,  701-702 

diagnosis,  696-697 

frequency,  692 

lateral,  695 

marginal,  695 

and  presentation  of  cord,  831 


INDEX 


1141 


Placenta  praevia  and  shoulder  presenta- 
tion, 429 
symptoms,  695-696 
treatment,  697-701 
in  twin  pregnancies,  818 
varieties  of,  695 
and  vertex  and  pelvic  presen- 
tation, 418 
reflexal,  694 
removal  of,  634 

in    atonic    hemorrhage,    865- 
866 
retained  fragments  as  cause  of  post- 
partum haemorrhage,  865 
retention  of,  572,  633-634,  874 
aetiology,  S74-875 
cause     of     subinvolution     of 

uterus,  949 
frequency,  874 
and  putrefaction  of  in  puerperal 

fever,  911 
treatment,  875-876 
in  secondary  abdominal  pregnancy, 

640 
secretion  of,  Bouchard  on,  95 
serotinal,  694 

structure  at  term  and  after,  8993 
succenturiata,  519-520 
syncytium,  90-92 
syphilis  of,  512-514 
trophoblast,  89-91 
'  truffie,'  524 
Placental  or  fibrinous  polypus,  618 

site  during  puerperium,  442 
Playfair  on  abortion  from  scarlatina,  567 
on  conception  of  phthisical  women, 

562,  563 
on  internal  version,  1012 
on     mortality     from      pneumonia 

during  pregnancy,  565 
on  ovarian  tumours,  801 
on    small-pox    during    pregnancy, 

569 

on  use  of  colpeurynter  for  reposi- 
tion, 536 
Playfair-Partridge  method    of  treating 
face  presentation,  386,  387 

treatment    of    brow    presentation, 

.  .394 

Pleuritis  and  peritonitis,  927 

Pluriparity  a  cause   of  abnormal  pre- 
sentation, 367 

Pneumonia,  '  deglutition,'  607 
during  pregnancy,  564-565 

Podalic  version,  see  under  Version 

Polygnathians,  854 

Polyhydramnios,  505 

Polymelians,  854 

Porak  on  late  ligation  of  the  funis,  1080 

Poroschin  on  degeneration  of  the  uterine 
muscle  and  rupture  of  the  uterus,  879 


Porro's     operation,     1036,    1037-1038, 
1047,  1048 
in    accidental    hemorrhage,    686, 
687 
Posterior    asynclitism,    312,     327-328, 

33i. 
commissure,  31 
Postural    treatment    of  transverse    lie, 

436-437 
of  prolapse  of  cord,  834,  835 
Poupart's  ligament,  672 
Prague  method  of  delivery  of  the  after- 
coming  head,  1030- 1032,  1034 
Pregnancy,  abdominal,  637  638 
secondary,  640 
abnormal  permeability  of  the  mem- 
branes, 487 
acute     yellow    atrophy    of     liver 
during,  576-577 
treatment,  577 
age   of,   methods   of  ascertaining 

239-242 
ampullar,  653-659 
anaemia  during,  476-477 
bladder  irritability  during,  474-475 
cancer  of  the  uterus  during,  results 

of  cases,  799-800 
cardiac  disease  and,  587-595 
cardiac   lesions   in,    treatment    of, 

589-590 
causes    of   enlargement    of    uterus 

other  than,  234-236 
certain  signs  of,  233 
chorea  during,  577-580 

treatment  of,  579-580 
chorion-epithelioma    during,    496- 

S05 

complications  of,  244,  246 
condition  of  uterus  during,  260 
connection    of  osteomalacia  with, 

779 
cornual,  638,  658-659 
decidual  endometritis  during,  480- 
487 
use  of  strychnine  during,  486 
diabetes  mellitus  in,  580-582 
rarity  of,  580-581 
treatment  of,  581-582 
diagnosis,  differential,  234-236 

importance   of  methods,   224- 
225,  227 
digestive  disorders  during,  469-472 
diphtheria  during,  555*556 
disorders   of  the   nervous    system 
during,  478-479 
of  urinary  system  during,  473- 

475 
of  the   vascular  system,   475- 
478 
duration  of,  mode  of  determining, 
205-206 


1 142 


INDEX 


Pregnancy,  eclampsia  in,  relative  rate 
of  mortality  from,  613 
during,    time   of  onset,    605- 
606 
effect  on  milk,  1088,  1089 
enteric  fever  in,  treatment  of,  558- 

559 
ergot  during,  486 
erysipelas  during,  559 
treatment  of,  560 
examination  of  cervix  in,  174 
excess  of  C02  in  uterine   sinuses 
and  general  circulation  during, 
255-256 
extra-uterine,  637-672 
aetiology,  641-644 
diagnosis,    661-662,    664-665, 

668-670 
hemorrhage  from,  673 
operations  for  removal  of,  671- 

672 
ruptured,  symptoms,  678 
symptoms,  660-661 
treatment,  662,  665-666,  670- 

672 
unruptured,  symptoms,  678 
varieties,  637-638 
haemorrhages  during,  673-705 
haemorrhoids    and   varicose   veins 

during,  475"476 
Hegar's  sign  of,  180-181 
history  of  patient,  162-163 
hydremia  during,  477-478 
hydramnios  during,  505-510 
'  hygiene  of  baths,  246-248 
incontinence  of  urine  during,  474- 

475 
infectious  diseases  in,  554-575 
influenza  during,  560-561 

treatment,  561 
infundibular,  659 
insanity  during,  939-941 

causes,  939-940 

prognosis,  941 

symptoms,  940 

treatment,  940-941 
insomnia  during,  478-479 
inspection  of  patient,  163 
interstitial,  638-649,  659,  661,  669 
isthmial,  638-649,  649-653,  661 
longings  during,  479 
lumps  in  skin  of  axillae  during,  453 
measles  during,  561-562 

treatment  of,  562 
menstrual  irritation  during,  256 
mesometric,  640,  651-652 
molar,  493 

recurrence  of,  498 
morning  sickness  during,  469-471 
multiple,  710 

aetiology,  809-812 


Pregnancy,  multiple,  a  cause  of  pro- 
lapse of  cord,  832 
complications,  818-819 
connection   with  hydramnios, 

506 
course  of  labour,  815-816 
determined  by  cardiac  sounds, 

185 

diagnosis,  814-815 

frequency,  808-809 

interlocking,  820-821 

labour  in,  815-816 

management,  817-818 

pregnant  uterus  increased  by, 
509 

prognosis,  819-820 

sex  and  development,  813-814 

and  shoulder  presentation,  428 

see  Twins 
nephritis  in,  582-587 
neuralgia  during,  478 
ovarian,  637 

pelvic  contractions,  effect  of,  on, 
726,  727 

joints,  changes  in,  during,  453 
phantom,  236 
phenomena  of,  206-223 
phthisis  during,  562-564 

treatment  of,  564 

question  re  artificial  termina- 
tion of,  564 
pneumonia  during,  564-565 

treatment  of,  565 
possible  signs  of,  233 
prevention  of,  1046 
probable  signs  of,  233 
retention  of  urine  during,  473-475 
in  rudimentary  horn,  551 
salivation  during,  472 
separation    of  membranes   during 

last  month  of,  255 
single  or  multiple,  method  of  deter- 
mining, 243 
situation,    importance     of     deter- 
mining, 243 
small-pox  during,  569-571 

treatment  of,  570-571 
symptoms,  objective,  by  abdominal 
auscultation,  230-233 

foetal  heart,  230,  233 

foetal    movements,    229,   230, 

233 
hypertrophy  of  ureters,   232, 

233 

recognition    of    foetal    parts, 

229,  230,  233 
uterus,  alterations  in,  231-232, 
.233 
syphilis  during,  571-574 
treatment,  573"574 
traumatisms  in,  704-705 


INDEX 


"43 


Pregnancy,  tubal,  550,  551,  638-672 
changes  in  tube  during,  645 
course  of,  638-641 
see  also  Extra-uterine 
tubo-ovarian,  645 
tubo-peritoneal,  645 
typhus  fever  during,  574-575 
umbilical  cord  in  first  months  of, 

97 
uterine  contractions  at  end  of  tenth 

month  of,  253-254 
in  uterus  bi-cornis,  549-550 
vesicular  mole  during,  488-496 
Pre-natal  impressions,  379 
Presentations,  125-133 

abdominal  palpation  for  diagnosis 

of,  166-172 
abnormal,  and  velamentous  inser- 
tion of  the  cord,  528 
statistics    of,    in    miscarriage, 

633 

abnormal  attitude,  129 
breech,  400,  401,  404 
cause  of  mal-presentation,  427 
cephalic,  126-133,  300-398 

aetiology,  405 

anterior  fontanelle,  aetiology, 

394-395 
definition,  394 
diagnosis,  395 
management,  396 
mechanism,  396 
positions,  395 
prognosis,  396 
brow,  aetiology,  389-396 
definition,  387 
diagnosis,  390-392 
frequency,  387-389 
management,  393-394 
mechanism,  392-393 
moulding  of  head  in,  393 
positions,  390 
prognosis,  394 
statistics     in     contracted 
pelvis  and  all  cases,  727 
causes  of,  300-303 
conversion    of    shoulder    pre- 
sentation into,  433 
face,  373-374,  375.  376",  377 
aetiology,  361-367 
application  of  the  forceps 

in,  1002-1003 
comparison    with    pelvic, 

410 
conversion  of  brow   pre- 
sentation into,  393-394 
definition,  361 
diagnosis,  367-370 
frequency,  361 
management  of,  379-387 
mechanism,  370-372 


Presentations,    cephalic,    face,    abnor- 
malities,   reversed 
rotation   of   head, 
377-378 
descent,  372 
extension,  372-37 
moulding  of  head  in,  379 
positions,  367 
prognosis,  387 
statistics,  727 
posterior  fontanelle,  ce'.iology, 

396-397 

causes,  394 
definition,  396 
diagnosis,  397 
management,  398 
mechanism,  397-398 
moulding  of  head  in,  398 
positions,  397 
prognosis,  398 
statistics  of,  300 
and  use  of  forceps,  990 
vertex,  397 

aetiology,  300-303 
application  of  the  forceps 

in,  993-1001 
cause,  394 

conversion  of  brow  pre- 
sentation into,  393- 

395 
of  face   presentation 

into,  382  386 
of    pelvic    presenta- 
tion into,  417-418 
danger  of  pelvic  presen- 
tation compared  to  that 
of,  417-418,  422 
frequency,  300 
means    and    methods    of 

diagnosis,  306-310 
mechanism, abnormalities, 
anterior      asyncli- 
tism, 328-33 T 
abnormalities,  hyper- 
rotation    of 
head,  324 
lateral  obliquity 
of    the    head, 

327. 

posterior  asyn- 
clitism, 327- 
328 

reversed  rota- 
tion of  the 
head,  persis- 
tent occipito- 
posterior  posi- 
tion, 325-327 

reversed  rota- 
tion of  the 
shoulders,  324 


1 144 


INDEX 


Presentations,  cephalic,  vertex,  mechan- 
ism, descent,  311- 

expulsion  of  the 
trunk,  322 

extension,  319-322 

external  rotation, 
319-322,  323,  324 

first  position,  back  to 
left,  322-323 

flexion,  314-316,322, 

323,  324 
head   in    relation   to 

pelvis,  309-312 
internal         rotation, 

316-319,  322,  323, 

324 
rotation,  309-310 
second  position,  back 
to  right,  323-324 
moulding  of  head  in,  331 
positions,  303-306 
posture  of  patient  during, 

334. 
statistics,  403 

in  contracted,  727 
compound,  825 

foot  or  feet  with  head,  828 
aetiology,  828 
diagnosis,  828 
effect  upon  labour,  828 
frequency,  828 
treatment,  829 
hand  or  arm  with  head,  825 
causes,  826 
diagnosis,  826 
effect  on  labour,  826-827 
frequency,  825-826 
prognosis,  828 
treatment,  827-828 
hand  with  the  breech,  829 
hands  and  feet,  829 
determined  by  cardiac  sounds,  185 
diagnosed  by  auscultation,  183 
mal-presentations,  743 

cause  of  prolapse  of  cord,  832 
myomata  a  possible  cause  of, 

792 
pelvic  contractions  a  cause  of, 

and  statistics,  726-727 
in      rachitic     generally     con- 
tracted flat  pelvis,  756 
mechanism,  in  bilateral  synostotic 
pelvis,  772 
in  dwarf  pelvis,  743-744 
in  flat  pelvis  on,  751-753 
in  pelvic  contraction  on,  728- 

729 
in  rachitic  generally  contracted 
flat  pelvis  on,  756 
in  multiple  pregnancies,  812-813 


Presentations,    occipito-posterior    posi- 
tion of  the  head,  application  of 
forceps  in,  1001-1002 
pelvic,  126,  128,  129,  130,  427 
aetiology,  405-407 
application  of  the  forceps  in, 

1003 
breech,  400,  401,  404 
complete,  400 

conversion   of  face    presenta- 
tion into,  386 
of  shoulder  presentation 
into,    by    spontaneous 
version,  433-434>   434" 

.  .435 
definition,  399 
diagnosis,  407-410 
effect  on  fcetus,  417-418,  422- 

423 
extraction    of    the    fcetus   in, 
indications,  1016 
operation,  1016 

delivery  of  the  after- 
coming  head, 1030- 

1035. 
extraction      of     the 
pelvic  pole,   1016- 
1024 
liberation     and     de- 
livery of  the  arms, 
1024-1030 
foot,    or    footling,   400,    401, 

404,  406-407,  416 
frequency,  401-405 
incomplete,  400-401 
knee,  400,  401,  404,  406-407, 

416 
management,  417-423 
mechanism,        abnormalities, 
foot  and  knee  presen- 
tations, 416 
abnormalities,      reversed 

rotation  of  head,  416 
comparison  with  cephalic, 

410 
descent,   411,    414,    415, 

416 
expulsion   of    trunk   and 

head,  413-414 
external  rotation,  412-413 
first  position,  back  to  the 

left,  414-415 
internal      rotation,    411, 

4H.4I5 
latero-flexion    of    trunk, 

411-412,  414,  415 
rotation,  414,  415,  416 
moulding    of    the    head    in, 

4.17 
positions,  407 
prognosis,  422-423 


INDEX 


I H5 


Presentations,      pelvic,      prophylactic 
podalic  version,  731 
statistics  in  contracted  pelvis 
and  all  cases,  727 
and     prophylactic     treatment      of 

uterine   ruptures,  884 
fetus,    shoulder,     126,    129,    130, 

425 
in   presentation   and    prolapse   of 

cord,  837-839 
podalic  version,  see  tliat  title 

post-partum   effects  of  pelvic 
contraction,  729-730 
postural  treatment,  podalic  version, 

436-438 
shoulder,  causes,  etiology,  427-430 
diagnosis,  431  -433 
frequency,  425-427 
internal  version,  1013-1015 
larger  proportion  of  male  than 

female  infants  met  in,  436 
management  of,  436-438 
mechanism,  433 
positions,  430-431 
prognosis,  438 

statistics     of,     in     contracted 

pelvis  and  in  all  cases,  727 

terminations,     birth     corpore 

conduplicato,  435-436 

spontaneous      evolution, 

434-435 
spontaneous  version,  433- 

434 

statistics  of  influence  of,  on   mor- 
tality among  twins,  820 

in  transverse  and  oblique  lies,  see 
Shoulder,  above 

vaginal  examination  of,  174-176 
Priestley,  memoirs  of  Simpson  by,  428 

on  abortion,  621 

on  syphilis  as  cause  of  intra-uterine 
death  of  foetus,  616 

on  vesicular  mole  and  pregnancy, 
488 
Primiparse,  accidental  haemorrhage  in, 
683 

albuminuria  more  frequent  in,  582- 

cervical  changes  in,  in  premonitory 

stage,  286 
correction    of  pelvic    presentation 

desirable  in,  418 
diabetes  in  pregnancy  rare  in,  581 
duration  of  labour,  285,  289 

in  cases  of  occipito-posterior 

position  of  the  vertex,  326 
of  first  stage  of  labour,  287 
of  second  stage  of  labour,  289 
eclampsia,   rate  of  mortality  from, 

613 

frequency  among,  601,  602 


Primiparse,  fixation  of  foetal   head  in 
premonitory  stage,  287,  288 
insanity   during   pregnancy     more 

frequent  in,  939 
laceration  of  vaginal  canal  in,  448 
lax  abdominal  wall  seldom  found 

in,  418 
length  of  different  stages  of  labour 

in,  257 
loss  of  weight  in,  during  puer- 
perium  less  than  in  multipara?, 
.452  _  _ 
micturition  during  puerperium,  454 
more  liable  to  septic  infection,  918 
mortality  from  cardiac  disease  in, 

590-591 
pains  during  puerperium,  455 
pelvic  presentation  in,  danger  of, 
and  statistics  of  foetal  mortality, 
422 
perinatal  lacerations,  893 
placenta  prasvia  less  frequent  in,  692 
presentation  in,  172 
prolapse  of  cord  more  frequent  in 

multipara?  than  in,  832 
proportion    of  shoulder   presenta- 
tions in  multipara?  and,  428 
rigidity  of  uterine  fibres  in,  805 
statistics   of  infants    died    during 

labour  and  after  birth,  299 
statistics  of  pelvic  presentation  in, 

402-403 
taking  up  of  the  cervix  in,  264-266, 

267 
tearing  of  posterior  commissure  of 

the  vagina,  274 
treatment    of   spasmodic   contrac- 
tions of  the  cervix  in,  718-719 
uterine  orifice  in,  719 
vesicular   mole    more   frequent    in 

multipara?  than  in,  488 
weight  and  length  of  foetus,  108 
Probyn-Williams  on  pulse-rate  during 

puerperium,  450 
Probyn-Williams   (and    Cutler),    respi- 
ratory rate  during  puerperium,  453 
Procidentia  uteri,  543-544 
Prolapse  of  cord,  percentage  of  breech 
presentation  in,  832 
of  face  and  brow  presenta- 
tion in,  832 
of  shoulder   presentation 

in,  832 
of  vertex  presentation  in, 
832 
of  hand  alongside  head,  foetal,  429 
of  uterus,  543-544 
of  vaginal  walls,  544 
Pryor   on    treatment   of    local    septic 

infection,  929-930 
Pseudencephalians,  851 


1 146 


INDEX 


Pseudo-cyesis,  236 
Psoas  muscle,  63 
Psodymes,  855 
Ptyalism,  see  Salivation 
Pubis  in  kyphotic  pelvis,  774 

anatomy  of,  18 

in  split  pelvis,  790 
Pubo-coccygeus  muscle,  62 
Pubo-sacral  band,  64 
Pudendum,  30 

see  also  Vulva 
Puerperal  fever,  aetiology,  904 

causes  of,  139,  141 

epidemics  of,  905 

identity  with  septic  infection,  141 

nomenclature  of,  902-904 

parasitic   organisms  causing,   907- 
911 

predisposing  causes  of,  911-913 

putrefactive  organisms  in,  911 

statistics  of,  139-140 

or  surgical  fevers  of  childbed,  901- 

936 
Puerperal  osteophytes,    occurrence   of, 

during  pregnancy,  223 
state,  see  Puerperium 
ulcer,  919 
Puerperium,    cancer     of    the      uterus 

during,  results  of  cases,  799-800 
changes  in  breasts  during,  448-449 
changes  in  circulatory  system  and 

pulse-rate,  449-450 
changes  in  the  genital  tract  during, 

441-448 
condition     of      abdominal     walls 

during,  453 
condition  of  pelvic  joints  during, 

.453 
diagnosis  of,  455 
digestive  system  during,  452 
diphtheria    of    vulva    and    vagina 
during,  920 
douching,  460-462 
duration  of,  441 

eclampsia  in,  rate  of  mortality  from, 
613 
time  of  onset,  605-606 
fistulas  during,  after  uterine  inertia, 

712 
haemorrhage  during,  see  Secondary 
post-partum,  under  Haemorrhage 
insanity  during,  940-945 
causes  of,  941 
prognosis,  943 

symptoms  and  course,  941-942 
treatment,  942-943 
lochia  during,  444-446 
loss  of  weight  during,  452 
lymphatic  sepsis,  931-932 
management  of  bladder,  457-458 
of  digestion,  456-457 


Puerperium,  management  of  lactation, 
462-464 

medical  visits,  465 

of  rectum,  458 

sleep,  464 

of  uterine  involution,  458-462 
mastitis  during,  945 
micturition  during,  454 
pains  during,  455,  464-465 
prognosis  and  possible   complica- 
tions, 465 
pulmonary  embolus  in,  948-949 

symptoms,  948 

treatment,  948  949 
pyaemia,  934"936 
respiratory  system  during,  453 
skin  during,  453 

sub-involution  of  uterus  in,  949-951 
super-involution  of  uterus  in,  951 
symptoms,  454-455 
temperature  during,  450-451 
urinary  system  during,  451-452 
uterine   contractions   during,  454- 

455 
weight,  size,  and  height  of  uterus 
during,  446-447 
Pulse-rate  of  infant,  1084 
during  puerperium,  450 
in   spasmodic    contraction  of    the 
uterus,  716 
Purefoy   on   inversion   of  uterus,  895, 
1004 
on  statistics  of  icterus  neonatorum, 
1 106 
of  forceps  deliveries,  1004 
Purgatives  during  pregnancy,  246,  471 
during  labour,  333 
green  diarrhcea  in  infant,  1 105 
Putrefaction  of  fcetus,  619 
Pyaemia,  934-935 
diagnosis,  936 
symptoms,  935-936 
treatment,  936 
Pyriformis  muscle,  64 
Pyrosis,  471,  472 

Quadruplets,  aetiology,  811 

frequency,  808 
Quickening,   prediction  of  date  of  de- 
livery from  date  of,  240 

as  a  sign  of  pregnancy,  225-226 
Quintlets,  frequency,  809 

Ramsbotham  on  nausea  and  vomiting 

during  pregnancy,  469 
Recht,  statistics  of  micturition  during 

puerperium,  454 
Rectum,  58 

changes  in,  during  pregnancy,  218 
distended,  effect  on  uterus,  447 
in  case  of  haematocele,  664 


INDEX 


1 147 


Rectum  in  labour,  273 

management      of,     during     puer- 

perium,  458 
in  secondary  uterine  inertia,  715 
Registrars-General    of    England     and 
Ireland,     mortality    returns     during 
labour,  298-299 
Reichert  on  early  human  ovum,  104 
Reid  on  duration  of  pregnancy,  205-206 
Reinicke  on  disinfection  of  hands,  149 
Relapsing  fever  during  pregnancy,  565- 
566 
rarity  of,  565 
'  Relaxation,'  definition  of,  257 
Renal  disease,  placenta  of,  524 

cause  of  decidual  endometritis,  484 
of  accidental  haemorrhage  in 

pregnancy,  683 
of  eclampsia,  582,  584-7 
Reposition  of  ovarian  tumour,  802-803 
of  cord,  838 

definition,  834 
instrumental,  836-837 
manual,  835 
postural,  834-835 
Respiration,  effect  of  post-hsemorrhagic 
collapse,  870 
of  infant,  1097 

in  spasmodic  contraction  of  uterus, 
716 
Respiratory  sounds,  185 
Respiratory  system,  changes  in,  during 
pregnancy,  222 
after    delivery    and     during    puer- 
perium,  453 
Restitution,  or  external  rotation,  320 
'  Retraction,'  definition  of,  257 
Re-vaccination,       correspondence       in 
British  Medical  Journal  re,  570 
of  mother  during  pregnancy,  effect 
on  infant,  570 
Rheinstadter  on  cause  of  morning  sick- 
ness, 470 
Ribemont-Dessaignes     on      accidental 
traumata,  705 
on  amount  of  fluid  in  hydroceph- 
alus, 843 
on  cephalic  application  of  forceps, 

994 
on  eclampsia,  608 
on  force  of  uterine  contractions,  262 
on  frequency  of  placenta   praevia, 

692 
on  haemorrhage  in  placenta  praevia, 

695 
mucus  aspirator  devised  by,  159 
on    neurotic  theory  of  eclampsia, 

602 
on  placental  infarction,  524 
statistics    of  posterior  rotation   of 

fcetal  occiput,  325 


Ribemont-Dessaignes  on  tying  of  cord, 
1080 
on     uterine     contractions     during 

labour,  261 
on  vaginal  douches,  153,  246,  461 
on  weight  of  foetus,  108,  109 

figures    re    expulsion   of    the 

placenta,  283 
on  rotation  of  fcetal  head  by 

internal  manipulation,  349 
statistics  of  positions  in  vertex 
presentation,  304 
Ribes,  Champetier  de,  Martin's  method 

of  delivery,  1032 
Rickets,     723,     742,     750,    762,    787- 
788 
pelvic  flattening  produced  by,  740 
rachitic  triradiate  pelvis  caused  by, 

784 

Ricketts   on    small-pox    during    preg- 
nancy, 569-570 
Rigid  os,  718 
Rissel,    W.,    on    chorion-epithelioma, 

497 
Ritgen,  '  manoeuvre  of,'  in  preservation 

of  perineum,  345 
Riviere     on      Bouchard's     theory     of 

eclampsia,  604 
Robert's  pelvis,  see  Bilateral  synostotic 

under  Pelvis 
Robson,  Mayo,  ectopic  pregnancy,  663 
'Rcederer's  obliquity,'  316 
Rokitansky    on    enteric    fever    during 
pregnancy,  557 
on  puerperal  osteophytes,  223 
Roper  on  signs  of  incarcerated  gravid 

uterus,  535 
Rotch  on  lactoglobulin,  1087-1088 

on  menstruation  and   composition 

of  milk,  1088 
table  of  salts  in  human  milk,  1088 
Rotunda    Hospital,    anti-galactogogue 
used  in,  463 
artificial  feeding  in,  1094 
case  of  hypertrophy  of  cervix  in, 

544 
cases  of  hyperemesis   gravidarum 

at,  S95 
gonococcus  in  puerperal  fever  at, 

910 
intra-uterine  death  of  foetus  in,  615 
maternal   mortality  from   placenta 

praevia  in,  702 
method  of  bipolar  version  used  in, 

1009-1010 
narcotic  treatment  of  eclampsia  at, 

611-612 
prophylactic   post-partum    douche 

condemned  at,  461 
results  of  introduction  of  asepsis 

at,  139,  140 


INDEX 


Rotunda   Hospital,  statistics,  abortion 

at,  621 
of  accidental  haemorrhage  at, 

683 
of  brow  presentations,  388 
of  cephalic  presentations,  300 
of  chorea   during  pregnancy, 

577 
of  eclampsia  in,  598 
of  face  presentation,  361 
of  fcetal   and    maternal  mor- 
tality in  shoulder  presenta- 
tion, 438 
of   fcetal   mortality   in   pelvic 

presentation,  422 
of  haemorrhage,  864 
of  hydramnios,  505 
of  icterus  neonatorum,  1106 
of  internal  traumatic  haemor- 
rhage, 861 
of  inversion  of  the  uterus  in, 

895 
of  mortality,  old,  139,  140 
maternal,  297-299 
infantile,  299 
from  sepsis,  901 
of  pelvic  contraction,  722 
of  pelvic  presentation,  405 
of  placenta  previa,  692 
of  prolapse  of  cord,  829-830 
of  retention  of  the  placenta,  874 
of  rupture  of  uterus,  877 
of    secondary      post  -  partum 

haemorrhage,  869 
of  sex  of  twins,  814 
of  transverse  lies  in,  426 
of  twin  and  triplet  pregnan- 
cies, 808 
re  use  of  forceps,  1004 
of  vesicular  mole  in  pregnan- 
cies, 488 
summary    statistics    of    mortality 

among  twins,  819-820 
treatment    of    accidental    haemor- 
rhage at,  691 
cases  of  external  haemorrhage 
at,  688 
Routh  on  extra-uterine  pregnancy,  676 
Roy,  M.  le,  and  symphysiotomy,  1049- 

1050 
Rubeska  on  tetanus  in  childbed,  910 
Ruffel,  M.,  report  on  symphysiotomy, 

1049 
Ruge  on  maceration  of  foetus,  618-619 
Martin's  method  of  delivery,  1032 
Ruge,  P.,   on  weight  of  placenta  and 

fcetus  in  syphilis,  513 
Runge  on  cause  of  uterine  contractions, 
255-256 
on  effects  of  elevation  of  tempera- 
ture on  fcetus,  616 


Rupture  in  cornual  pregnancy,  659 
extra-peritoneal,  of  tube,  650-652 
intra-abdominal,  of  tube,  656 
intra-peritoneal,  of  tube,  650,  653- 

657 

of  hymen,  237 

primary,  in  extra-uterine  preg- 
nancy, 639-640,  649,  653,  659, 
662,  665 

secondary,  641,  653,  646,  665,  671 

Saccharomyces  albicans,  1105 
Sacro-coccygeal  tumours,  foetal,  849 
Sacrum,  1-3 

fracture  of,  788 

in  funnel-shaped  pelvis,  777 

in  obliquely  distorted  pelvis,  762, 
764,  765-766,  767 

in  osteomalacia,  780-781 

in  pelvis  of  congenital  dislocation 
of  the  hips,  758 

in  rachitic  flat  pelvis,  749 

in  split  pelvis,  790 

in  spondylolisthetic  pelvis,  784 

in  transversely   contracted   pelvis, 
770,  772,  774 
Sagittal  suture   327 

in  anterior  asynclitism,  329 

in  flat  pelvis,  752 

fcetal,  313 
Saint-Blaise,  Bouffe  de,  on  Bouchard's 
theory  of  eclampsia,  604 

on  hyperemesis  gravidarum,  596 
Salivation  during  pregnancy,  472 

treatment,  472 
Salpingo-oophoritis,  664,  925 
Sandstein  on  movement  of  pubic  bones 

in  Walcher's  position,  1052 
Sanger  on  changes  in  uterine    muscle 
during  involution  of  uterus,  443 

on  origin  of  chorion-epithelioma, 

497,  498 
on  suturing  in  Caesarean  section, 
1037,  1045-1046 
Sapraemia,  519,  913-918 
after  abortion,  630-631 
diagnosis,  916 

pathological  anatomy  of,  913 
symptoms,  914-916 
term  used  for  putrid  intoxication, 

9°3 

treatment,  916-918 
Saprophytic  infection,  '  mixed,'  928 
Sarcoma,  origin  of  chorion-epithelioma 

from,  498-499 
Sato,  case  of  quintlets  recorded  by,  811 
Savage,  pubo-coccygeus  muscle,  62,  64 
Savin-poisoning,    maternal,     cause     of 

intra-uterine  death  of  fcetus,  617 
Scarlatina  during  pregnancy,  566-569 
rarity  of,  566 


INDEX 


1 149 


Scarlatina  during  pregnancy,  treatment 
of,  568-569 
'  puerperal,'    controversy    re,    566- 

567 
Schaeffer  on  innervation  of  uterus,  254 
.on  effect  of  uterine  contractions  on 

fu-tUS,  277 

on  internal  pelvimetry,  197 

on      treatment     of     osteomalacic 

pelvis,  7S3 
on  vaginal  douching  during  puer- 

perium,  461 
Schaller  on  effect  of  phloridizin,  510- 

5ii 
Schatz  on  force  of  uterine  contractions, 
262 

method  of  converting  a  face  into 
a  vertex  presentation,  382-384, 
386  ^ 

method  of  determining  date  to 
induce  labour  in  pelvic  con- 
traction, 735 

on  peristaltic  character  in  uterine 
contractions,  261 

treatment    of    brow   presentation, 

394 

Schauta  on  torsion  of  the  cord,  527 

on  induction  of  labour  in  diabetics, 

582 
on  relative  rate  of  mortality  from 
eclampsia,  613 
Schmidt  on    ligation  of  the  cord  after 
birth  and  jaundice,  1080 
on  abdominal  palpation,  164 
Schmorl  on  eclampsia,  603 

on   tuberculosis   in    the   placenta, 
522 
Schbttin  on  urinjemic  theory  of  eclamp- 
sia, 603 
Schroeder  on   caruncuke   myrtiformes, 
36 
on  composition   of  lower   uterine 

segment  in  labour,  267-268 
on  funic  souffle,  187 
on  hypertrophy  of  cervix,  545 
on  separation  of  membranes  during 
last  month  of  pregnancy,  255 
Schucking  on  ligation  of  cord,  1080 
Schultze   on    degrees   of    inversion    of 
uterus,  895-896 
on   detachment  and  expulsion  of 

placenta,  280 
method    of    artificial    respiration, 
1098,  1099,   IIOO-IIOI 
Schumacher    on    urincemic    theory    of 

eclampsia,  603-604 
Schwab  on  placenta  in  syphilis,  514 
Schwyzer  on    urine  in  fetal  bladder, 

848 
Sciatic  notch,  27 
Scoliosis,  723,  762 


Scrotum  in  male  infant,  417 
Sedatives  for  eclampsia,  609 
Seegen   on    menstruation    in  diabetes, 
580 
on  miscarriage  from  diabetes,.  581 
Semmelweis,  measures  to  prevent  puer- 
peral fever,  139 
on  puerperal  fever,  906 
Sepsis,  prevention  of,  148-154 
Septic    absorption    in    chorion-epithe- 
lioma, 505 
in  endocarditis,  935 
infection,  296,  297,  299,  918-937 
in  pelvic  contraction,  729 
local,  919-931 

diagnosis,  928,  929 
symptoms,  927-929 
treatment  of,  929-931 
peritonitis,  802 
Septicaemia,  see  Lymphatic  sepsis 

puerperal     {see      also       Puerperal 
fevers),  903 
Sexlets,  frequency  of,  809 
Show,  275,  286 
Sigault,  revival  of  symphysiotomy  by, 

1049 
Silbermann  on  cause  of  icterus  neona- 
torum, 1 1 06 
Simpson,  compound  presentation,  825 
placenta   previa,  shoulder  presen- 
tation, 429 
on  separation  of  membranes,  last 
month  of  pregnancy,  255 
Simpson,  A.  R.,  on  super-involution  of 
uterus,  951 
spondylotomy  v.  decapitation,  43S 
Simpson,  Sir  J.,   on  internal  version, 

1012 
Simpson,  Sir  J.  Y.,  on  use  of  chlorate 

of  potassium,  620 
Sinclair,  Japp,  on  use  of  watch-spring 

pessary  for  reposition,  536 
Sir    Patrick    Dun's    Hospital,    enteric 
during  pregnancy  in,  558 
phthisis  during  pregnancy  in,  563 
Skene,  glands  of,  ^ 
Skin,  action  during  pregnancy,  246 

during  puerperium,  453 
Skinner  on   treatment  of  incarcerated 

uterus,  535-536 
Skull,  fetal,  109- 1 19 

Budin,  maximum  diameter  of, 

114 
characteristics  of,  109,  no 
circumferences     of,     1 14- 118, 

121 
diameters  of,  112-114,  121 
fontanelles,    principal,    acces- 
sory, 1 1 1- 1 12 
regions,  1 18- 119 
sutures  of,  no-iii 


i.i  So 


I 


INDEX 


Skutsch,   internal   pelvimeter   of,    199- 

202 
Slarjanski    on    cholera    and    decidual 

endometritis,  480 
Sleep  during  puerperium,  464 
Small-pox  during  pregnancy,  569-571 

dangers  of,  exaggerated,  569 
Smellie  on  cephalic  method  of  forceps 
application,  994 
method  of  delivering  after-coming 
head,  1032-1034 
in  flat  pelvis,  753 
in  hydrocephalus,  845 
on  rotation  of  fcetal  head,  349 
Smyly  on  abdominal  palpation,  164 
on  accessory  fimbriated  extremity, 

643 
on  case  of  hypertrophy  of  cervix, 

544 
on  haemorrhage  in  chorion-epithe- 
lioma, 503 
and  use  of  post-partum  douche,  461 
Solayres'  obliquity,  312,  314 
Soxhlet's  apparatus  for  sterilising  milk, 

1093,  1094 
Spermatozoon  and  ovum,  641-644 
Sphincter,  475 

Spiegelberg  on  ansemia  of  kidneys  in 
eclampsia,  598 

on  cause  of  vesicular  moles,  489 
on  changes  in  uterine  muscle  during 

involution,  443 
on  classification  of  kyphotic  pelvis, 

770 
on     diagnosis     of     osteo-malacic 

pelvis,  782 
on  external  pelvimetry,  192 
on  funnel-shaped  pelvis,  778 
on  hernia  of  pregnant  uterus,  546 
on  kyphotic  pelvis,  773,  775 
on   malformations   of    uterus   and 

vagina,  549 
on  mortality   from  chorea    during 

pregnancy,  578 
on  nephritis  in  pregnancy,  583 
on  osteo-malacia,  779 
on   pregnancy    in    downward    dis- 
placement of  uterus,  543 
on  pulse-rate  during  puerperium, 

45o 
on  rupture  of  the  pelvic  articula- 
tions, 894 
on   spondylolisthetic    pelvis,    785, 

787 
statistics  of  face  presentation,  361 
of  double  monsters,  857-858 
of  mortality  in  pelvic  contrac- 
tion, 738 
of  perineeal  laceration,  893 
of  presentation    in    cases    of 
contracted  pelvis,  727 


Spiegelberg,  statistics  on  treatment  of 
pelvic  contraction,  734 
of  twin  presentations,  813 
on  unilateral  synostotic  pelvis, 
768,  769 
Spina  bifida,  848-849 

in  connection  with  hydrocephalus, 
844 
Spleen,  necrosis  of  in  eclampsia,  600 

tumours  of  fcetal,  849 
Spondylizema,  or  pelvis  obtecta,   775, 

784 
Spondylolisthesis,  784-787 
Spondylotomy,  438 

Spontaneous  version,  see  under  Version 
Staphylococcus  pyogenes  aureus,  923 

in  puerperal  fever,  907,  908 
Stchegoleff  on  iodoform,  156 
Stengel  on  pregnancy  in  diabetics,  581 
Stenosis  of  cervix,  805-807 

of  the  vagina  and  vulva,  807 
Stephenson,      summary     of     Rotunda 
Hospital  statistics  of  mortality  among 
twins,  819-820 
Sterilisation,  141 

dressings  and  instruments,  150-151 
Stevens,  height  of  uterus  above  sym- 
physis during  puerperium,  447 
Stewart  on  urinsemic  theory  of  eclamp- 
sia, 603-604 
Stoltz    on    menstruation   during   preg- 
nancy, 704 
Stomatodaeum    in    first-month    foetus, 

104 
Strassman    on  site   of    fertilisation   of 

ovum,  642 
Streptococcus   pyogenes    in    puerperal 
fever,  907-908 
in  puerperal  ulcer,  919 
Striae  gavidarum,  217,  253 
Stricture  of  the  uterus,  717 
Stroganoff     on     bacterial     theory     of 

eclampsia,  602 
Strychnine  during  pregnancy,  486 
Stumpf's  theory  of  eclampsia.  602-603 
Submucous    myoma,     confusion    with 

chorion-epithelioma,  5°4 
Sue   on   hereditary   tendency   to    twin 

pregnancies,  811 
Superfecundation,  81 1 
Superfoetation,  811-812 
Stisserot   on   relation   of    myomata   to 
oblique  lie  of  foetus,  428 
statistics  of  mortality  in  myoma  of 
uterus,  798 
Sutugin   on  height  of  uterus  in  preg- 
nancy, 211 
Sutures  an  aid  to  diagnosis  of  vertex 
presentation  of  fcetal  skull,  no-ill, 
308 
Sutton,  Bland,  see  Bland- Sutton 


INDEX 


i 


1151 


Swanzy   on    blindness  from   nephritis, 

584 
Sycephalians,  854,  S55 
Symelians,  850 
Symphysis  pubis,  18,  275 

changes  in,  during  labour,  275 
Symphysiotomy,   733,   753,   754,    1038, 
1049-1050 

after-treatment,  1058-1059 

in  case  of  excessive  sized  foetus,  841 

effect  on  pelvis,  1051-1053 

indications,  1053- 1055 

operation,  1056-1058 

prognosis,  1059 
Symphysis,  fcetal,  313 

height    of    uterus    above,    during 
puerperium,  447 

in  kyphotic  pelvis,  775 

in  obliquely  distorted  pelvis,  763, 
765,  767 

in  spondylolisthetic  pelvis,  784 

relations  to  true  conjugate,  197-198 

rupture  of,  894 
Syncytium,  the,  90,  91,  491,  492 

as    origin   of  chorion-epithelioma, 
498,  499 
Synotosis  of  both  sacro-iliac  joints,  772 

of  one  sacro-iliac  joint,  765 
Syphilis,   congenital,   changes  in  liver 
of  foetus,  516 

in  connection  with  foetus,  515-518 

contra-indication  to  nursing,  464 

parental,     intra-uterine    death    of 
fcetus,  615-616,  617 

precipitate  labour,  710 

during  pregnancy,  571-574 
Sysomians,  854,  855 

Tait,  Lavvson,  on  normal  site  of  fertilisa- 
tion of  ovum,  641 
on  primary  intra-peritoneal  rupture 
of  tube,  656 
Tarnier,     determining     influences     on 
weight  of  fcetus,  108 
on  milk  diet  in  cases  of  albumin- 
uria, 608 
on  time  of  onset  of  eclampsia,  605- 

606 
on  rotation  of  fcetal  head,  349 
statistics  of  twin  presentations,  813 
Taylor  on  cause  of  tubal  pregnancy,  644 
on  cornual  pregnancy,  670 
on  intra-peritoneal  rupture,  656 
Teacher  on  Langhans'  layer,  491 
on  chorion-epithelioma,  499 
Telolecithal  ova,  71 
Temperature  of  infant,  1084 

during  puerperium,  450-451 
Teradelphians,  854,  855 
Teratocephalians,  851-852 
Teratodymes,  854.  855 


Terato-encephalians,  851,  852 

Teratoma,  fatal,  849 

Teratomelians,  850 

Teratopagians,  853,  855 

Teratosomians,  851 

Tetanus  uteri,  716 

Tetanus  in  uterine  contraction,  714 

Theca,  56 

Thermin,  statistics,  mortality  in  cases 

of  myoma  of  uterus,  798 
Thompson    on    phthisis    during    preg- 
nancy, 562 
Thoracopagous  monsters,  856 
Thorax,  changes  in,  during  pregnancy, 

218 
Thrombi  in  uterine  sinuses,  444 
Thrombosis  in  pelvic  cellulitis,  925-926 

in  septic  infection,  924 
Thrush,  1105-1106 
symptoms.  1106 
treatment,  1106 
Thyroid  extract  in  eclampsia,  610 

gland,     diminution     in     secretion 
cause  of  eclampsia.  601 
enlargement  of,  221 
Todd  on  urine  in  chorea,  579 
Toloczinow    on    uterine    tumours    and 

shoulder  presentation,  427-428 
Tonic  spasm,  716-717 
Toxalbumins,  932 

Toxin,    removal    of,    from    blood    and 
tissues  important  in  eclampsia,  609- 
610 
Transverse  and  oblique  lies,  presenta- 
tions     in,      see      Shoulder,      under 
Presentations 
Traumata  during  birth,  1 109 
cause  of  abortion,  622 

of  accidental  hemorrhage,  684 
of  stenosis  of  cervix,  806 
genital,  see  Genital  traumata 
direct,    a     cause     of    rupture    of 

uterus,  878 
harm  wrought  by,  Gueniot's  con- 
clusions on,  705 
Triplets,  aetiology,  811 

frequency,  808 
Trismus  uteri,  717 
Trophoblast,  500 
Trophoblastic  cells,  89 
True  conjugate,  9,  337 
Trypsin  in   digestive   system  of  fcetus, 

io3 
Tubal  mole,  formation  of,  646 
Tubera  ischii,  781 

in  pelvis  of  congenital  dislocation 

of  the  hips,  758 
in  rachitic  flat  pelvis,  750 
in  spondylolisthetic  pelvis,  784 
in   transversely  contracted   pelvis, 
77i,  774 


1152 


INDEX 


Tuberculosis,  antenatal,  522 

placental,  522 
Tuefferd  on  rising  of  uterus  with  vesicular 

mole,  493 
Tumours  and  Caesarean  section,  1038 
fcetal,  390 

cause    of    shoulder    presenta- 
tions, 429 
intra-tubal,  a  cause  of  extra-uterine 

pregnancy,  643 
ovarian,  552-553 
of  the  ovaries  during  labour,  800- 

804 
pelvic  deformities  from,  787-790 
placental,  520-521 
and  pregnancy,  234-235 
secondary  post-partum  haemorrhage 

caused  by,  869 
in  uterus,  406,  552-553 
of  uterus  and  shoulder  presentation, 

427-428 
uterine,     cause     of     post-partum 

haemorrhage,  865 
of  vagina  and  vulva,  804-805 
see  also  Particular  names 
Turner,  table  of  date    of  secretion   of 
true  milk,  449 
on   urinary   system   during    puer- 
perium,  451 
Tussenbroeck    on    ovarian   pregnancy, 

637 
Twins,  distension  of  uterus  in,  255 
effect  on  uterus,  406 
and  hydramnios,  506 
aetiology,  809-812 
cause   of    abnormal    presentation, 

367. 
complications,  818-819 
cause  of  labour,  815-816 
diagnosis,  814-815 
frequency,  808 
interlocking,  820-821 

diagnosis,  821-823 

treatment,  823-824 
ligation  of  cord  in,  1082 
loss  of  weight  during  puerperium, 

452 
management,  817-818 
method  of  determining  presence  of, 

in  pregnancy,  243 
parasites  found    in  cases  of,  from 

one  ovum,  852 
prognosis,  819-820 
race  and  heredity,  8 10-8 1 7 
sex  and  development,  813-814 
and  shoulder  presentation,  428 
statistics,  presentations,  813 
in  uterus  bi  cornis,  549 
and  vesicular  mole,  489,  493 
Typhus   fever   during  pregnancy,  574- 
575 


Umbilical  cord,  anomalies  of,  524-528 
arteries,  97 
covering,  97 

dressing  of  infant's  wound,  1083 
in  first  months  of  pregnancy,  97 
freeing    of,    during    expulsion    of 

foetus,  346-347 
handling   of,    in    pelvic    presenta- 
tion, 420-421 
lengthening  of,   in  third  stage  of 
labour  and  method  of  straighten- 
ing loop,  292-293 
length  of,  96 

ligation  of,  after  birth,  1079- 1082 
presentation   and    prolapse,   aetio- 
logy, 830-832 
consequences,  832 
definition,  829 
diagnosis,  832-833 
frequency,  829-830 
prognosis,  839 
treatment,  833-839 
removal  of  the  placenta  by  traction 

on,  354 
shortness  of,  429 
syphilitic  lesions,  514-515 
veins,  97 
velamentous     insertion     in     twin 

pregnancies,  819 
Wharton's  jelly  in,  97-98 
Umbilical  infection,  infantile,  1107-1108 
prognosis,  1 108 
treatment,  1108 
Umbilical  souffle,  187 
Umbilical  vein,  101  103 
Umbilicus,   state  of  vein   after    birth, 

103 
Unguentum  Crede,    use   in    lymphatic 

sepsis,  934 
Ureters,  57-58 

changes  in,  during  pregnancy,  217- 

218 
hypertrophy  of,  as  a  sign  of  preg- 
nancy, 232,  233 
Urethra,  272-273 

Urethral  caruncle,  ante-partum  haemor- 
rhage from,  704 
Urinaemic  theory  of  eclampsia,  603-604 
Urinary  organs,  fcetal,  abnormalities  of, 

848 
Urinary   system,    changes    in,     during 
pregnancy,  222 
disorders   during  pregnancy,  473- 

475 
during  puerperium,  451-452 
Urine,  of  infant,  1084-1085 

incontinence  of,  during  pregnancy, 

474-475 
causes,  474 
treatment,  475 
involuntary  escape  of,  485 


INDEX 


"53 


Urine,  retention  of,  during  pregnancy, 
aetiology,  473 
diagnosis,  473"474 
symptoms,  473 
treatment,  474 
suppression  of,  398 
Urobilin  in  eclampsia,  601 
Urogenital  cleft,  32 

triangle,  60 
Uterine  asepsis,  maintenance  of,  459- 

460 
Uterine      contractions,      atonic      post- 
partum     haemorrhage     due     to 
failure  of,  863 
cause  of  labour,  253,  254 
character  of,  261,  262 
delivery  during,  343-344 
and  detachment  and  expulsion  of 

placenta,  350 
duration  of  labour  dependent  on, 

285 
effect  of  ergot  on,  359-360 

on    fcetal    cardiac   sounds   of, 

185-186 
of  myoma  on,  792 
effects  of,  on  fcetal  body,'  316 
on  maternal  system,  284 
on  ovum,  263,  275-284 
on  pelvic  contents,  271-273 
on  pelvic  joints  and  ligaments, 

274-275 
on  perinseum,  273-274 
on  uterus,  263-271 
ftetal  heart-rate  during,  833 
in  first  stage  of  labour,  2S7,  339 
and  internal  rotation,  319 
during  labour  in  pelvic  contraction, 

727,  728 
muscular  susurrus,  1S5 
in  pelvic  contraction,  730 
in  pelvic  presentation,  419,  421 
and  post-partum  traumatic  haemor- 
rhage. S60 
and  precipitate  labour,  709-710 
during  puerperium,  454-445 
retention  of  the  placenta,  874-875 
rupture,  of  the  uterus,  8S1,  882 
in  second  stage  of  labour,  290 
during  second  stage  of  labour,  347 
in  shoulder  presentation,  433,  434 
spasmodic,  715 
of  body,  716 

aetiology,  716 
diagnosis,  716-717 
prognosis,  717 
symptoms,  716 
of  cervix,  717-718 
aetiology,  7  1 8 
diagnosis,  71S 
prognosis,  719 
symptoms,  718 


Uterine    contractions,     spasmodic,     of 
cervix,  treatment,  718-719 
strength  of,  262-263 
tonic,  714 

transmission  to  foetus,  311 
in  unduly  prolonged  labour,  294 
and  use  of  forceps,  993 
and  uterine  inertia,  711-715 
and  vesicular  moles,  495 
Uterine  douche,  465 

for  atonic  haemorrhage,  866 
during  puerperium,  461-462 
in  secondary  post-partum  haemor- 
rhage, 869 
Uterine  enlargement  and  morning  sick- 
ness, 470 
Uterine  inertia,  71 1 

cause  of  post-partum  haemorrhage, 

865 
primary,  711 

aetiology,  7 1 1 
diagnosis,  712 
prognosis,  713 
symptoms,  71 1-712 
treatment,  712-713 
secondary,  713 

setiolcgy,  713-714 
diagnosis,  714 
in  hydrocephalus,  844 
prognosis,  7*5 
symptoms,  714 
treatment,  712,  714-7 15 
and  use  of  forceps,  993 
Uterine    involution,    management    of, 

during  puerperium,  458-462 
Uterine  muscle,  289 

changes      during      involution       of 

uterus,  442-443 
degeneration      of,      and      uterine 

rupture,  879 
in  third  stage  of  labour,  291 
Uterine  orifice,  definition,  258 
Uterine  souffle,  183-184 

connection    with    contractions    of 

uterus,  184 
as  sign  of  pregnancy,  230,  233 
various  authors  on,  184 
Utero-iliac  band,  64 
Uterus,   abortion  from  causes  affecting 
attachment     of     ovum     to, 
622 
from     interference    with    de- 
velopment of,  622 
alterations  in,  and  anterior  asyncli- 
tism, 329 
as    signs    of   pregnancy,    231- 
232,  233 
amputation  of,  1038,  1039 
anteflexion    (pathological),    causes 

of,  539 

diagnosis,  540 

73 


"54 


INDEX 


Uterus,  anteflexion  (pathological),  con- 
genital malformation  cause 

of,  539 

prognosis,  540-541 

result    of    operative    interfer- 
ence, 539 

results  of  inflammation,  539 

symptoms,  539"54° 
anterior    development,    diagnosis, 

538 

displacements,    anteflexion,    treat- 
ment, 540 

anterior   development,   symptoms, 

537-538 

treatment,  538 
anteversion,  causes  of,  541-543 

symptoms,  542 

treatment,  542-543 
auscultation  of,  1 82- 1 88 
displacements  backward,  529"53^> 

949 
a  cause  of  abortion,  484 
bacteriology  of,  146 
bi-cornis,  429,  548,  549-55°,  55 * 
pregnancy     in      rudimentary 
horn,  638,  658-659 
bi-manual     compression     of,      for 

atonic  haemorrhage,  868 
bloodvessels   and  lymphatics,    47- 

49 
cancer  of,  798-800 
cervix,  see  that  title 
changes  in,  in  vesicular  mole,  493" 

494,  495 
during  pregnancy,  207-21 1 
in  fundus  of,   in   premonitory 

stage,  287 
in  tubal  pregnancy,  647-648 
condition    during    pregnancy    and 

labour,  260,  261 
connections  of,  43-44 
contraction    of  muscular  coat   and 
cessation    of    haemorrhage, 
864 
as  sign  of  pregnancy,  229-230, 
233,   see   also   Uterine  con- 
tractions 
cordiformis.  548 
decidua  of,  83 
defective  development  and  removal 

of,  1039 
development  of,  547-549 
dextro-torsion      of      and      uterine 

souffle,  184 
didelphys,  548,  549 
dilatation  of  uterine  orifice,  267 

in  pelvic  contraction,  727 
dimensions  of,  42-43 
diminution  in  size  of  upper  uterine 

segment,  271 
displacements  of,  539-546 


Uterus  douches,  152,  154 

double,  menstruation  during  preg- 
nancy due  to,  703 
downward  displacements,  543-544 
duplex  separatus,  548 
effect  of  contractions  of  accessory 
muscles,  263 
of  dwarf  pelvis,  742,  743 
of  ergot,  359-360 
of  flat  pelvis,  753 
of  hydrocephalus,  844 
of  pelvic  contraction  on,  729 

during  pregnancy,  726 
of  rachitic  generally  contracted 

flat  pelvis  on,  757 
of    uterine    contractions     on, 
263-271 
emptying  of,  in  hsemorrhage,  681- 

682 
controversy  ?-e  emptying  of  uterus 

in  eclampsia,  610-612 
enlargement,    causes     other    than 

pregnancy,  234-236  _ 
ex  pansion  of  lower  uterine  segmen  t, 

267-271 
expulsion  of  placenta  from,   350- 

356 

extirpation   necessary  in   chorion- 
epithelioma,  504 
faulty  innervation,  cause  of  uterine 

inertia,  71 l 
fibro-myoma  of,  791-798 
forward  displacements,  538-543 
'healthy,' 685,  688 
hernia  of  pregnant,  diagnosis,  546 

treatment  of,  546-547 
in  hydramnios,  507-508 
incarceration,  diagnosis,  534"535 

increased       intra  -  abdominal 
pressure,  cause  of,  531 

peritoneal  adhesions,  cause  of, 
531-532 

prognosis,  537 

of  a  retroverted,  751 

symptoms,  532-534 
inversion  of,  895 

aetiology,  895-896 

degrees.  895 

diagnosis,  896-897 

frequency,  895 

prognosis,  897 

removal  of,  in,  897 

symptoms,  896 

treatment,  897 
involution,  441-444,  452 
lesions   of,    and    septic    infection, 

919-925 
ligaments,     changes     in,     during 

pregnancy,  215-216 
lower  uterine  segment,  275 
malformations,  547-551 


INDEX 


"55 


Uterus  malformations,  diagnosis,  550 
and     shoulder     presentation, 

429 
treatment  of,  550551 
method  of  removing  clot,  464-465 
mobility  increased    in  third   stage 

of  labour,  293 
myomata  in,  704 
myomatous,  534 
nerves  of,  49-50,  254 
in  nulliparity  and  parity,  239 
obliquities,  a  cause  of   compound 

presentation,  826 
pathological   anteflexion   of,     539" 

polarity  of,  definition,  257 

position  of,  44-45 

prediction  of  date  of  delivery  from 

height  of,  240-241 
pregnant,  conditions  which  increase 
size,  509 
diagnosis  of  by  palpation,  166 
hernia  of,  546-547 
retroverted,  and   hematocele, 
664,  665 
in    presentation   and    prolapse   of 

cord,  831-832 
pressure  on,  in  pelvic  presentation, 

421 
primary  inertia,  71 1 
procidentia  symptoms,  543-544 

treatment,  544 
prolapse  of,  543-544 

and  retention  of  urine  during 

pregnancy,  473"474 
symptoms,  543"544 
treatment,  544 
putrid       endometritis       of       and 

saprsemia,  913,  916 
relations  of  foetus  to   122-136 

of  shape  of  foetus  to  shape  of, 
126-127 
retraction  of  muscle  fibres,  864 
retrodeviation,  869 
rising   of  fundus  in  third  stage  of 

labour,  293 
rupture  of,  433,  877 
etiology,  877-879 
diagnosis,  882-883 
exostoses  a  cause  of,  789 
frequency,  877 

pathological  anatomy,  879-880 
prognosis,  888-889 
in  shoulder  presentation,  438 
symptoms,  880-881 
treatment,  active,  885-888 
prophylactic,  883-885 
septic  endometritis  in,  920-925 
septus,  429 

bi-locularis,   548 
structure  of,  45-47    259,  260 


Uterus,  sub-involution  of,  950-951 
etiology,  950 
symptoms,  949 
treatment,  950-951 
super-involution  of,  951 
cetiology,  951 
symptoms,  951 
treatment,  951 
tumours,  552-553 

cause  of  post-partum  hemor- 
rhage, 865 
and     shoulder     presentation, 

427-428 
treatment  of,  552-553 
in  unduly  prolonged  labour,  294 
unicornis,  549 

weights  and  capacity  of,  207 
weight,    size,    and   height   during 
puerperium,  446-447 

Vagina,  37-39 

alterations   in,    as   signs    of  preg- 
nancy, 230-232,  233 
bacteriology  of,  142-146 
catarrh  of,  919-920 
changes  in,  during  pregnancy,  216 
cicatrisation      and      removal      of 

uterus,  1039 
diphtheria  of,  920 
douches    during    pregnancy,    246- 
247 
of,  for  and  against,  151-154 
effect  of  dwarf  pelvis  on,  744 
of  flat  pelvis  on,  753 
of  pelvic  contraction  on,  729 
inflammation  of,  551-552 
expulsion  of  placenta  from,   350- 

356. 
laceration  of,  890 
diagnosis,  891 
symptoms,  890 
treatment,  891 
lesions   of,    and    septic    infection, 

919-920 
malformations  of,  547-551 
malignant    disease    of,    cause     of 

ante-partum  hemorrhage,  704 
in  nulliparity  and  parity,  238 
prolapse  of,  and  retention  of  urine, 

473 

of  walls  of,  544 

treatment  of,  544 
plugging  in  accidental  hemorrhage, 
688-689,  690.  691-692 

in  placenta  previa,  700 
septa,  548 
stenosis  of,  807 
tumours  of,  804-805 
vault  in  unduly  prolonged  labour, 

294 
Vaginal  canal  during  puerperium,  448 

73—2 


1156 


INDEX 


Vaginal  douche  in  atonic  hemorrhage, 
866 
during  puerperium,  460-462 
in  laceration  of  the  vagina,  891 
in  secondary  post-partum  haemor- 
rhage, S69 
uterine  inertia,  715 
in  spasmodic  contractions,  717 
Vaginal  examination,  173-182,  288,  474 
in  bilateral  synostotic  pelvis,  773 
cancer  of  the  uterus  diagnosed  by, 

798  . 
in  chorion-epithelioma,  503 
complications  determined  by,  176- 

diagnosis    of    anterior    fontanelle 
presentations  by,  395 
of  brow  presentations  by,  390- 

39i 
of  face  presentation  by,  369- 

37o 
of  foetal  oedema  by,  847 
of  hydrocephalus  by,  844 
of    myomata     in     the    pelvic 

cavity  by,  794 
of    pelvic     presentation     by, 

408-410 
of  posterior  fontanelle  presen- 
tation by,  397 
of    presentation    in    case    of 
monsters,  853 
of  foot  or  feet  with  head 

made  by,  828 
of    hand    or    arm    with 

head,  826 
or  prolapse  of  cord  made 
by,  832-833 
of  shoulder  presentation   by, 

432-433 
of  stenosis  of  the  cervix  in, 
806 
of  vagina  and  vulva,  807 
of  vertex  presentation  by,  308- 

3°9 
in  kyphotic  pelvis,  775 
necessary  during  end  of  first  stage 

in  pelvic  presentation,  419 
in  pelvic  contraction,  724 
in  pelvic  tumours,  789 
relative  advantages   and   possibili- 
ties of,  188-189 
in  secondary  uterine  inertia,  714 
in    spasmodic  contraction    of    the 

cervix,  718 
in  unilateral  synostotic  pelvis,  768, 

769 
in  version,  1011 
Vaginal  ovariotomy,  804 
Vaginal  wall,  272^73 
Vaginal    walls   and   internal   rotation, 
316-317 


Vaginitis,  551 

gonorrhoea  and  prolapse  causes  of, 

5Si 
prognosis,  551-552 
septic,  927 
treatment,  551 
Varicose  veins,    see  Haemorrhoids  and 

varicose  veins 
Varnier  on  duration  of  labour  in  cases 
of  occipito-posterior  position  of 
vertex,  326 
on    management    of    the    bladder 

during  puerperium,  457 
position  of  the  placenta,  518 
on  weight  of  uterus  after  delivery, 
446 
Vascular   system,    disorders    of,   during 

pregnancy,  475-478 
Vassali,  case  of  quintlets  recorded  by, 

809 
Veit  on  detachment  of  placenta,  683 
on  frequency  of  quadruplets,  808 
morphia    treatment    for   eclampsia 

introduced  by,  609,  612 
on  origin   of  chorion-epithelioma, 

„498-499 

Veit-Smellie  method  of  delivery,  1032- 

i°34 
Velpeau  on  multiple  pregnancy,  811 
Veniat  on  enteric    fever  during   preg- 
nancy, 557-558 
Ventral  ovariotomy,  804 
Verneuil     on      surgical      intervention 

during  pregnancy,  705 
Vernix  caseosa  in  foetus,  105,  107 
Version,  bi-polar  or   combined,    1006, 
1008 
operation,  1008-IOIO 
indications,  1008 
cephalic,   1005,  1006,   1007,  1008- 
1009,  1010 
in  transverse  lie,  437 
contra-indications,  1006 
external,  1006-1007 
indications,  1007 
operation,  1007 
internal,  1006,  1010 
indications,  1010 
operation,  1010-1015 
podalic,  1005 

in    case     of    excessive    sized 

foetus,  841 
in  presentation  of  foot  or  feet 

with  the  head,  829 
for  presentation  and  prolapse 

of  cord,  837,  838 
in  prolapse  of  arm  alongside 

head,  328 
in    unavoidable   haemorrhage, 
698 
prophylactic,  1054 


INDEX 


1157 


Version,  prophylactic,  podalic,  730-733, 
744-745,  753 
spontaneous,  433-434 
Vesicular      mole      during     pregnancy, 
etiology,  4S8-490 
connection     with     chorion-epithe- 
lioma, 500 
diagnosis,  495 
hemorrhage  from,  673-756 
in  pregnancy,  673,  674,  675,  678 

frequency,  488 
pregnant  uterus  increased  by,  509 
prognosis,  496 
symptoms,  493-494 
treatment,  495-496 
Vesicular     moles     during     pregnancy, 

pathological  anatomy,  490-493 
Vestibule,  32-34 
Vicarelli  on  acetone  in  urine  prior  to 

delivery,  452 
Virchow  on  chronic  endometritis  and 
vesicular  moles,  489 
on  decidual  endometritis,  483 
on     liver     changes    in     syphilitic 

foetus,  516 
on  myxoma  fibrosum,  521 
on  necrosis  of  liver  in  eclampsia,  600 
term  '  myxoma  chorii,'  488 
Virginity,  hymen  in,  237-238 
Vitelline  circulation,  81-104 
Von  Franque  on  vesicular  mole,  490 

on  chorion  epithelioma,  505 
Von  Herff  on    peristaltic  character  in 

uterine  contractions,  261' 
Von  Jiirgensen  on  infection  of  fcetus, 
measles,  561-562 
on  '  puerperal '  scarlatina,  567 
on  rarity  of  scarlatina  during  preg- 
nancy, 566 
Vulva,  30 

dilatation  of,  during  labour,  290 
alterations   in,    as   signs   of   preg- 
nancy, 230-232 
bacteriology  of,  142-143 
changes  in,  during  pregnancy,  216 
diphtheria  of,  920 
laceration  of,  890,  893-894 
lesions   of,    and    septic    infection, 

919-920 
stenosis  of,  807 
swelling  of,  in  premonitory  stage, 

286-287 
tumours  of,  S04-805 
in  virginity,  nulliparity,  and  parity, 
237-238 
Vulvitis,  septic,  927 

Wade  on  digital  dilatation  of  the  os  as 

cure  for  chorea,  579 
Walcher's  position,  337-338,  841 
in  contracted  pelvis,  731,  736 


Walcher's  position,  movement  of  pubic 

bones  in,  1052 
Waldeyer  on  the  cervix,  39 

on  the  ovaries,  52 
Warmann  on  recurrence  of  molar  preg- 
nancies, 489 
Webster  on  aetiology  of  placenta  previa, 
692,  693 
on  causes  of  tubal  pregnancy,  643- 

644 

on  changes  in  uterine  muscle,  443 

on  cornual  pregnancy,  659 

on  decidual  cells,  85 

on  interstitial  pregnancy,  649 

on  intra-peritoneal  rupture,  653- 
654,  656 

on  position  of  uterus  during  puer- 
perium,  447 

on  primary  intra-peritoneal  preg- 
nancy, 637-638 

on  projection  of  pelvic  floor  during 
puerperium,  448 

on  reflexal  placenta,  694 

on  separation  of  the  membranes 
during  last  month  of  pregnancy, 

25S 
on  tubal  pregnancy,  645,  647 
Weight,    loss    of,    during    labour    and 

puerperium,  452 
Wenzel     on     mortality    from     chorea 

during  pregnancy,  578 
Wernich,    effect   of    ergot    on    uterus, 

359. 

on  weight  of  fcetus,  108 
Werth    on    rupture     of    broad     liga- 
mentous pregnancy,  652 
Whartonian  jelly,  absence  of,   in  cord, 

515 

Wharton,  jelly  of,  in  umbilical  cord, 

97-98 
White    (Manchester)     on    ligation    of 
cord  after  birth,  1080 
on     non-recumbent     position      in 
puerperium,  912 
Widal     on    infection    of    fcetus    with 

enteric,  558 
Wigand  on  abdominal  palpation,  164 
external    version   first    introduced 
by,  1807,  1006 
Wigand-Martin    method   of    delivery, 

1032,  1034 
Williams,     Dawson,     on     measles     in 

pregnancy,  561-562 
Williams,  Sir  J.,  on  changes  in  uterus 

during  puerperium,  444 
Williams,  Whitridge,  497 

on  Bacillus  coli  in  puerperal  fever, 

908,  909,  910 
on  Cesarean  section,  1039,  1046 
on  chorion-epithelioma,   497-498, 
504 


"58 


INDEX 


Williams,    Whitridge,    on    method    of 
preventing   future    pregnancies, 
after  Csesarean  section,  1046 
on  case  of  hyperemesis  gravidarum, 

595.  597 

on  gonococcus  in  puerperal  fever, 
910 

on  placental  infarction,  523 

statistics  of  results  of  cases  of 
Caesarean  section,  1048 

on  symphysiotomy,  1059 

on  treatment  of  local  septic  infec- 
tion, 929 

on  use  of  forceps,  1002 

on  vaginal  bacteriology,  143,  144, 

Willis  on  puerperal  fever,  905 
Winckel  on  abnormal  insertion  of  cord, 

528 
on  anterior  asynclitism,  329 
on  bi-polar  version,  1008 
on    cause   of    internal    traumatic 

haemorrhage,  861 
on  causes  of  inversion  of  uterus, 

896 
on  causes  of  precipitate  labour,  710 
on    changes    in     uterine     muscle 

during  involution,  443 
on     chronic      endometritis      and 

vesicular  moles,  489 
on  decapitation,  1073 
on  expectant  treatment  of  incom- 
plete abortion,  631 
on  fcetal  cardiac  sounds,  185 
on   fcetal    hydrencephalocele    and 

hydromeningocele,  846 
on    fcetal    prognosis   in    maternal 

hydramnios,  510 
on  formation  of  knots  in  umbilical 

cord,  524 
on  funic  souffle,  187 
on  generally  contracted  pelvis,  742 
on  heart-rate  during  contractions 

of  uterus,  284 
on  hernia  of  pregnant  uterus,  546 
on  hypertrophy  of  cervix,  545 
on  internal  version,  1012 
on   intra-uterine    death   of    foetus 

from  eclampsia,  617 
on  laxative  effect  of  colostrum  on 

the  infant,  449 
on  loss  of  blood  during  labour,  863 
on   loss   of  weight    during    puer- 

perium,  452 
on  Martin's   method   of  delivery, 

1032 
on  maternal  mortality  from  placenta 

praevia,  702 


Winckel  on  maternal  respiratory  rate 
during  pregnancy,  284 
on  placenta  praevia  and  twin  preg- 
nancies, 818 
on  four  positions  of  foetus,  133 
on    post-partum    haemorrhage     in 

twin  pregnancies,  818 
on  positions  in  shoulder  presenta- 
tion, 430-431 
on   presentation   and    prolapse   of 

cord,  831,  832 
on  prolapse  of  arm  alongside  head, 

827 
on  proportion  of  male  and  female 
infants  in  transverse  or  oblique 
lies,  430 
on  pubic  bones  in  split  pelvis,  790 
on  spasmodic  contraction,  715 
statistics,  fcetal  and  maternal  mor- 
tality in  shoulder  presenta- 
tion, 438  _ 
frequency  of  internal  traumatic 

haemorrhage,  861 
frequency  of  non-rachitic  and 

rachitic  flat  pelves,  745 
maternal  and  fcetal  mortality, 

738 
on     frequency     of      anterior 
asynclitism,  756 
of    oblique     distortion     of 

pelvis,  761 
of  placenta  prsevia,  692 
pelvic  contraction,  722 
pelvic  presentations,  402,  403 
positions   in   pelvic  presenta- 
tion, 407 
presentation    of    hand    with 

head,  825 
transverse  lies,  426 
vertex  presentation,  403 
table  of  intervals  between  first  and 

second  foetus,  816 
on  uterine  souffle,  184 
on    urinary   system    during    puer- 

perium,  451 
on  version,  1010 
Winter  on  accidental  haemorrhage,  683 

Xiphopagous  monsters,  856 

Ziegenspeck  on    determination  of  sex 
by  fcetal  cardiac  sounds,  185 
on  foetal  heart-rate  during  uterine 

contractions,  284 
on  treatment  of  face  presentations, 
386 
Zona  pellucida,  69-70 
Zweifel  on  symphysiotomy,  1058-1059 


Bailliere,  Tindall  and  Cox,  8,  Henrietta  Street.,  Covent  Garden,  London. 


This  book  is  due  oil  theNdate  indicated  below,  or  at  the 
expiration  of  a  definite  period,  after  the  date  of  borrowing,  as 


provided  oy  tne  rules  or  tne  l^iorary  or  Dy  spt 
ment  with  the  Librarian  in  charge. 

iciai  arrange- 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

t 

"DiflL'S. 

JW%    5  1 

U)j^a^ 

' 

c28(ii4i)mioo 

^KQrZ~L><r  ;pj3 


\AeAV«i>0<* 


VW*A  oW   Y\^ 


v>^v 


rv 


4f>R      fc  1944        £•  ^cy^ 


